Name
Age
Mobile
Email
What were you treated for?
At which Hospital and when was the Surgery done?
Please rate us on a scale of 1 -5 for the following parameters
(1 is extremely satisfied and 5 is extremely dissatisfied)
PRE OPERATIVE CONSULTATION
Thoroughness of Examination and time spent
Behavior of Doctor/ Staff
Waiting Time at clinic/ Appointment
Explanation of Problem & Surgery
Queries explained satisfactorily
Fees & Charges
Were you referred to any place for Hearing Tests/ Xray/ CTScan/ Blood Tests? Rate your overall experience on scale of 1to 5
SURGERY DAY EXPERIENCE
Behavior of Hospital Staff
Behavior of Doctors
Punctuality
Fees as per Estimate /Insurance payment
POSTOPERATIVE EXPERIENCE
Time taken for recovery as explained before
Thoroughness of Examination
Fees & charges
Explanation of
Queries
Overall, how satisfied are you with the treatment? Please rate us on a
scale of 1-5 (1 is extremely satisfied and 5 is
extremely dissatisfied)
Would you recommend
us to a friend? Why?
How did you come to
know about us?( Yellow Pages/ Friends/ Internet)
Any Comments /
Suggestions?
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