IP FEEDBACK FORM
First Name
Last Name
Gender
Female
Male
IP Number
Consultant Name
Bed Category
Bed Number
Date Of Admission
Date Of Discharge
Contact Number
Referred By
Utkal Hospital works hard to improve our services and care. Your feedback helps us get better. Please share your thoughts so we can serve you well.
What influenced your decision to choose Utkal Hospital? (Tick one or more as applicable)
Location
Doctor Preference
Corporate tie-up/Doctor Referral
Reputation
Web site Advertising
Friend/Family Recommendation
Service Experience
Admission experience (admission staff behavior and helpfulness)
Poor
Below Average
Average
Above Average
Excellent
Nursing experience (behavior and availability of nurses)
Poor
Below Average
Average
Above Average
Excellent
Doctor experience (adequate time provided, communicative and ease of access)
Poor
Below Average
Average
Above Average
Excellent
House Keeping (Cleanliness hygiene and responsiveness)
Poor
Below Average
Average
Above Average
Excellent
Infrastructure and maintenance (Room facilities like AC, beds, lights, telephone, food table, etc.)
Poor
Below Average
Average
Above Average
Excellent
Dietary (Food quality and on time service)
Poor
Below Average
Average
Above Average
Excellent
Operation Theatre (OT) (If availed) (procedure explained, staff responsiveness, post-surgery monitoring)
Poor
Below Average
Average
Above Average
Excellent
ICU (If availed) (staff responsiveness and care and treatment provided in the ICU)
Poor
Below Average
Average
Above Average
Excellent
Emergency (If availed) (waiting time, doctor and nursing staff responsiveness)
Poor
Below Average
Average
Above Average
Excellent
Discharge & billing experience (If availed) (billing staff behavior and responsiveness)
Poor
Below Average
Average
Above Average
Excellent
How long did you wait after the doctor approved your discharge?
More than 3 hrs.
Between 2hr - 3hr
2 hrs
Between 1hr - 2hr
Less than 1hr
How Likely are you to recommend Utkal Hospital to your family and friends?
😡(Very Unlikely)
🙁(Unlikely)
😐(Somewhat Likely)
🙂(Very Likely)
Suggestions to improve our hospital.
Would you like to appreciate any individuals? Please share their name & your experience.
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