Feedback Form

1. How did you hear about CIWEC hospital?

 Signage/ Advertisements
 Family/ Friends/Word of mouth
 Internet
 Travel/ Guide Book
 Insurance Agency (Provide name)
 Travel Agents/Guides (Provide name)
 Medical Provider (In your Country or in Nepal)
 City Map

2. What was the reason for your hospital visit?

 Consultation /Checkup Emergency Other

3. How do you rate the explanations provided by the staff on the procedures in the hospital?

 Excellent Very good Good Satisfactory Poor

4. How do you rate the doctor’s explanation of the details about your illness and related procedures?

 Excellent Very good Good Satisfactory Poor

5. How do you rate the time management by the hospital team to support your need during this hospital visit?

 Excellent Very good Good Satisfactory Poor

6. How do you rate the cleanliness/infection prevention practices in the hospital?

 Excellent Very good Good Satisfactory Poor

7. Was the check-in / check-out/ Registration process conducted professionally and to your satisfaction?

 Excellent Very good Good Satisfactory Poor

8. If you were hospitalized (admitted), how would you rate the quality of food provided by the hospital?

 Excellent Very good Good Satisfactory Poor

9. If you were hospitalized (admitted), how would you rate quietness/comfort in the hospital?

 Excellent Very good Good Satisfactory Poor

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

 Yes Maybe No (Any reason)

11. In your opinion what are the strong points of this hospital?

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

13. Can we contact you with CIWEC Hospital updates? If Yes, Please provide preferred name and email address

Your Name

Your Email

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