Patient Feedback Form

Section A: Patient Information (Optional)

Age

Gender
MaleFemaleOther / Prefer not to say

How did you hear about our hospital?
—Please choose an option—Friend/Family recommendationInternet searchReferral from another doctorSocial mediaOther

Section B: Visit Details

Purpose of this visit
Routine eye examSurgical consultationFollow-upEmergency / Urgent careOther

Was this your first visit?
YesNo

Section C: Registration & Check-in Experience

How easy was the registration process?
Very easyEasyNeutralDifficultVery difficult

How long did you wait before seeing the doctor?
Less than 15 minutes15-30 minutes30-60 minutesMore than 60 minutes

Section D: Clinical Care & Staff Interaction

Did the doctor explain your diagnosis clearly?
Yes, very clearlySomewhat clearlyNot clearly

Doctor Rating (1-5)
Patience:
Confidence:

Medical Staff Friendliness
ExcellentGoodFairPoor

Front Desk & Support Staff (1-5)

Courtesy:
Clarity:
Responsiveness:

Pharmacy Staff (1-5)

Courtesy:
Clarity:
Responsiveness:

Section E: Treatment & Follow-Up

Were medicine instructions clear?
YesNoNot applicable

Procedure explanation rating (1-5)

Section F: Facilities & Cleanliness (1-5)

Cleanliness:
Signage:
Comfort:
Washroom:

Section G: Overall Satisfaction

Overall satisfaction
Very satisfiedSatisfiedNeutralDissatisfiedVery dissatisfied

Improvement since last visit
Improved significantlyNo improvementDeteriorating

Condition after treatment
Improved significantlyImproved somewhatStayed the sameWorsened

Would you recommend us?
Definitely willProbably willMight or might notProbably won’tDefinitely won’t

Suggestions for improvement