Feedback Form

1. What was the reason for your hospital visit?

 Outpatient Emergency Dental Other

2. During this hospital visit, how well did the staff explain procedures and instructions to you?

 Very well Ok Poor

3. During this hospital visit, how well did the doctor explain details about your illness, related procedures?

 Very well Ok Poor

4. Were your requests for assistance answered in a reasonable amount of time?

 Yes Most of the time Sometimes No

5. During this hospital visit, was the area around your room kept quiet?

 Yes Most of the time Sometimes No N/A(outpatient)

6. Was the check-in / check-out / Registration process conducted professionally and within a reasonable amount of time?

 Yes No N/A

7. Would you recommend this hospital to your friends and family?

 Yes Maybe No (Any reason?)

8. Please let us know if there was anything you would like to see us improve? Any comments?

9. How did you hear about CIWEC Hospital?

 Self/Internet/Signage Family/Friends Insurance Agency(Provide Name) Travel Agents/Guides(Provide Name) Embassy/Workplace(Provide Name)

Can we contact you with CIWEC Hospital updates? If Yes, Please provide Name & Email

10. Your Name

11. Your Email