CLINIC FEEDBACK FORM ☐ Consultation with doctor/nurse
☐ First aid treatment
☐ Medical check-up
Date: ____________________
☐ Medicine request
Employee Name (Optional): ____________________
☐ Follow-up visit
Department: ____________________
☐ Others (please specify): _______________
1. Purpose of Visit (Check all that apply)
2. Quality of Service
☐ Consultation with doctor/nurse
Please rate the following on a scale of 1 to 5 (1 = Poor, 5 =
☐ First aid treatment
Excellent)
☐ Medical check-up
☐ Medicine request Criteria 1 2 3 4 5
☐ Follow-up visit Courtesy of staff ☐ ☐ ☐ ☐ ☐
☐ Others (please specify): _______________ Waiting time ☐ ☐ ☐ ☐ ☐
2. Quality of Service Quality of medical assistance ☐ ☐ ☐ ☐ ☐
Please rate the following on a scale of 1 to 5 (1 = Poor, 5 =
Cleanliness of clinic ☐ ☐ ☐ ☐ ☐
Excellent)
Criteria 1 2 3 4 5 Availability of medicines/supplies ☐ ☐ ☐ ☐ ☐
Courtesy of staff ☐ ☐ ☐ ☐ ☐ 3. Comments and Suggestions
_________________________________________________________
Waiting time ☐ ☐ ☐ ☐ ☐ _________________________________________________________
Quality of medical assistance ☐ ☐ ☐ ☐ ☐ Would you like to be contacted regarding your feedback?
Cleanliness of clinic ☐ ☐ ☐ ☐ ☐ ☐ Yes (Please provide contact details: _______________)
Availability of medicines/supplies ☐ ☐ ☐ ☐ ☐ ☐ No
Thank you for your feedback! Your input helps us
3. Comments and Suggestions improve our services.
_________________________________________________________
_________________________________________________________
Would you like to be contacted regarding your feedback?
☐ Yes (Please provide contact details: _______________)
☐ No
Thank you for your feedback! Your input helps us
improve our services. CLINIC FEEDBACK FORM
Date: ____________________
Employee Name (Optional): ____________________
Department: ____________________
1. Purpose of Visit (Check all that apply)
CLINIC FEEDBACK FORM ☐ Consultation with doctor/nurse
☐ First aid treatment
Date: ____________________ ☐ Medical check-up
Employee Name (Optional): ____________________ ☐ Medicine request
Department: ____________________ ☐ Follow-up visit
1. Purpose of Visit (Check all that apply) ☐ Others (please specify): _______________
☐ Consultation with doctor/nurse 2. Quality of Service
☐ First aid treatment Please rate the following on a scale of 1 to 5 (1 = Poor, 5 =
☐ Medical check-up Excellent)
☐ Medicine request Criteria 1 2 3 4 5
☐ Follow-up visit Courtesy of staff ☐ ☐ ☐ ☐ ☐
☐ Others (please specify): _______________ Waiting time ☐ ☐ ☐ ☐ ☐
2. Quality of Service
Quality of medical assistance ☐ ☐ ☐ ☐ ☐
Please rate the following on a scale of 1 to 5 (1 = Poor, 5 =
Excellent) Cleanliness of clinic ☐ ☐ ☐ ☐ ☐
Criteria 1 2 3 4 5 Availability of medicines/supplies ☐ ☐ ☐ ☐ ☐
Courtesy of staff ☐ ☐ ☐ ☐ ☐ 3. Comments and Suggestions
Waiting time ☐ ☐ ☐ ☐ ☐ _________________________________________________________
_________________________________________________________
Quality of medical assistance ☐ ☐ ☐ ☐ ☐ Would you like to be contacted regarding your feedback?
Cleanliness of clinic ☐ ☐ ☐ ☐ ☐ ☐ Yes (Please provide contact details: _______________)
Availability of medicines/supplies ☐ ☐ ☐ ☐ ☐ ☐ No
3. Comments and Suggestions Thank you for your feedback! Your input helps us
_________________________________________________________ improve our services.
_________________________________________________________
Would you like to be contacted regarding your feedback?
☐ Yes (Please provide contact details: _______________)
☐ No
Thank you for your feedback! Your input helps us
improve our services.
CLINIC FEEDBACK FORM
Date: ____________________
Employee Name (Optional): ____________________
Department: ____________________
1. Purpose of Visit (Check all that apply)
