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Feedback Form
Client Feedback Form
Thank you for taking a moment to give feedback on our services. We appreciate you and want to improve based on your input
Document Ref. No: ABC/QML/010 (Annexure 01)
Review Due Date: 19/08/2022 Version No: 001
- Is this the first time you have used our service
Yes
No
- How satisfied were you with our service today
Highly satisfied
Satisfied
Barely satisfied
Not Satisfied
Timeliness
=====================================
- Did you receive your test report within the allocated time communicated to you?
Yes
No
If no, how much delay did you experience?
5minutes - 30minutes
30minutes - 1hour
2hours - 3hours
Respect & Privacy
=====================================
- The Level of respect shown to me by every member of staff was
Highly satisfactory
Satisfactory
Not satisfactory
- The Level of privacy available to me was
Highly satisfactory
Satisfactory
Not satisfactory
Level of respect and privacy
Reception
Lab
Mammogram
Ultrasound
X_ray
CT Scan
MRI
Security
Highly Satisfactory
Satisfactory
Not satisfactory
Facility
=====================================
- The environment is
Good
Average
Poor
The toilet(s) are
Good
Average
Poor
What could we do better
Any comment on any staff?
Any other comment?
Would you recommend us to a friend?
Full Name (optional)
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
Date
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Your ticket for the: Feedback Form
Title
Feedback Form
USD
