Hospital Customer Feedback Form Sample

Introduction: Effective customer feedback is crucial for improving hospital services and patient satisfaction. This sample feedback form is designed to gather comprehensive insights from patients about their hospital experience. It covers various aspects of care, including staff interactions, facility conditions, and overall satisfaction. The feedback collected through this form will help in identifying areas of improvement and enhancing the quality of service provided.

1. Personal Information

• Name (Optional): ___________________________
• Age: ___________________________
• Gender: Male / Female / Other
• Contact Information (Optional): ___________________________

2. Visit Details

• Date of Visit: ___________________________
• Department/Unit: ___________________________
• Reason for Visit: ___________________________

3. Overall Experience

• How would you rate your overall experience at our hospital?

  • Excellent
  • Good
  • Fair
  • Poor

• Please provide any specific comments or suggestions about your overall experience:

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4. Staff Interaction

• How would you rate the following aspects of staff interaction?

  • Courtesy and Respect: Excellent / Good / Fair / Poor
  • Responsiveness to Your Needs: Excellent / Good / Fair / Poor
  • Professionalism: Excellent / Good / Fair / Poor
  • Communication Clarity: Excellent / Good / Fair / Poor

• Please provide any specific comments or suggestions about staff interaction:

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5. Facility Conditions

• How would you rate the cleanliness and maintenance of the following areas?

  • Patient Rooms: Excellent / Good / Fair / Poor
  • Restrooms: Excellent / Good / Fair / Poor
  • Waiting Areas: Excellent / Good / Fair / Poor

• Please provide any specific comments or suggestions about facility conditions:

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6. Medical Care

• How would you rate the quality of medical care provided?

  • Excellent
  • Good
  • Fair
  • Poor

• Please provide any specific comments or suggestions about medical care:

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7. Discharge Process

• How would you rate the discharge process, including explanations and instructions given?

  • Excellent
  • Good
  • Fair
  • Poor

• Please provide any specific comments or suggestions about the discharge process:

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8. Additional Feedback

• What did you like the most about your visit?

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• What aspects do you think need improvement?

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9. Recommendation

• Would you recommend our hospital to others?

  • Definitely
  • Probably
  • Not Sure
  • Probably Not
  • Definitely Not

• Please provide any additional comments or suggestions:

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