FEEDBACK/COMPLAINT/SUGGESTION

YOUR FEEDBACK IS IMPORTANT TO US. IT'S HOW WE IMPROVE.

Emergency Patient Feedback Form

Date: 14-02-2026
Time: 03:10 PM
MRN No:

All information will be kept confidential and will only be used to provide better experience to our patients.

Exceptional: Exceeds expectations
Good: Completely meets expectations
Adequate: Sufficiently meets expectations but not fully
Unsatisfactory: Does not meet expectations

Please tick() as applicable:

1. How was your experience at registration? (Seamless, friendly & helpful)

2. How was your experience with your wait time? (Duration of wait time from registration to being seen by the doctor)

3. How was your experience with the staff nurses and paramedical staff in the Emergency? (Staff was helpful, treated me well and was empathetic)

4. How was your experience at the Pharmacy? (Accurate dispensation of medicines, explanation of frequency, min. wait time, seamless, friendly & helpful)

5. How was the experience with Billing? (Accuracy & explanation of itemized bill, seamless, min. wait time, friendly & helpful)

6. Rate the hospital’s cleanliness and directional for different services. (Directional to Immunization, pharmacy, X-ray room, billing etc.)

7. Comments on the overall experience of your Emergency visit today:

8. Suggestions/ complaints (if any):

9. Special mention for any staff (Name of the staff and your comments):

Name of the Respondent:
Contact no:
 
Please tick the box if you wish to receive a feedback (in case of a complaint).