Patient Name First Name Last Name MR Number Date of Admission - Month - Day Year Date Date of Discharge - Month - Day Year Date Phone Number Email example@example.com Guidelines: •To rate the following services that you received during your visit kindly tick in the box that represents your opinion. In case you did not receive any particular service; skip to the next question.•For rating Poor; we request you to give your suggestion for improvement. How did you come to know about Helios Hospital? Helios hospital doctor Reference of family doctor Corporate tie up/ Insurance company Website Hospital employee Relative/Friend Admission Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Doctor Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Nursing care Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Diagnostics (Pathology, Radiology, etc) Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Housekeeping Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Security Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Billing Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Discharge Poor 1 2 3 4 Excellent 5 1 is Poor, 5 is Excellent Overall experience Any suggestion you would like to put forward which will help us to serve you better? Would you like to recommend any staff for their work? Please specify name & reason. It was a pleasure caring for you. Get well soon. Submit Should be Empty: Now create your own JotForm - It's free! Create your own JotForm