Homeopathy Feedback Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you come to know about us
*
Referred by another patient
Practo
Google
Doctorcircle Videos
Signage
Other
How would you describe the ease of locating the clinic:
*
Difficult
1
2
3
4
Easy
5
1 is Difficult, 5 is Easy
What was the mode of your consultation, most of the time:
*
Online
Physical visit
Both
How would you rate the ambience at the clinic:
*
1
2
3
4
5
For what complaints, are you taking the treatment?
*
Duration of the treatment taken:
*
1 month
less than 3 months
less than 6 months
1-2 years
more than 2 years
How would you describe the outcome of the treatment taken so far:
*
Rows
Satisfied
Can be better
Not satisfied
Understanding of your complaints
1
2
3
Able to address your complaints
4
5
6
Outcome as described, so far
7
8
9
Assisting in your recovery (clarifications/queries)
10
11
12
Follow-up/ connectedness
13
14
15
Do you get the medications, couriered or delivered to you, from the clinic:
Yes
No
How were the courier services from the clinic:
*
Rows
Satisfied
Can be better
Not satisfied
Packaging
16
17
18
Instructions for taking the medicine
19
20
21
Delivery of the courier
22
23
24
How would you rate the treatment, with respect to 'value for the money':
*
not satisfied
1
2
3
4
satisfied
5
1 is not satisfied, 5 is satisfied
How is your feeling of well-being with the treatment:
*
25
1
2
3
4
5
6
7
8
9
26
10
1 is , 10 is
How likely are you to refer us to your friends/ family:
*
need time
1
2
3
4
easily
5
1 is need time, 5 is easily
Have you consulted for re-evaluation of the complaints you are suffering with:
*
Yes
No
Discontinued the treatment
Would you like to get connected back for the treatment with the clinic:
*
Yes
No
Which of these upcoming services would you be interested at the clinic:
Behavioral, Occupational & speech therapies
Physiotherapy
Yoga
Nutritionist
Psychological counselling
Hair & skin aesthetic solutions
Pharmacy
Kindly give your valuable suggestions, for improvement of the services:
*
Kindly let us know what is the best time to reach you back:
*
Submit
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