Healthcare Facility Feedback Poll
Help us improve by sharing your experience at our healthcare facility.
Your Full Name (optional)
First Name
Last Name
Date of Your Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department or Service Visited
*
Please Select
Emergency Room
Outpatient Clinic
Radiology/Imaging
Laboratory
Surgery
Pharmacy
Inpatient Ward
Other
How would you rate the cleanliness of the facility?
*
1
2
3
4
5
How would you rate the professionalism and courtesy of the staff?
*
1
2
3
4
5
How satisfied were you with the waiting time?
*
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
How would you rate the quality of care you received?
*
1
2
3
4
5
How well did staff communicate with you about your care or treatment?
*
Very Poorly
1
2
3
4
Very Well
5
1 is Very Poorly, 5 is Very Well
Please indicate your overall satisfaction with your visit.
*
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
What did you like most about your visit? (optional)
Do you have any suggestions for improvement? (optional)
Submit Feedback
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