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Consultant Feed Back Form
Customer Feedback Form
Place where the Service was Received:
Rehabilitaiton Center – Amitha
Rehabilitation Center – Adrutha
Rehabilitation Center – Tristar Care
Rehabilitation Center – Anunitha
Cadabams Hospitals – J P Nagar
Cadabams Mind Talk – Indiranagar
Date:
How likely are you to recommend our service to friends and family if they need similar care or service ?
Extremely Likely
Likely
Neither likely nor Unlikely
Unlikely
Extremely Unlikely
Don’t Know
The time you waited to be seen
The way you were greeted by staff
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Does Not apply
The way staff Listened to you
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
The information you were given( verbal & Written)
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
The opportunity you were given to ask questions
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
You overall experience of the service
Very Satisfied
Satisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
About you
I am
The Patient
Relative/Carer
Gender
Male
Female
Transgender
Please tell us your age
Under 18
18-35
36-55
56-75
76-85
Over 85
