INSTITUTE OF NEPHROUROLOGY
VICTORIA HOSPITAL CAMPUS , BANGALORE 560 002
OPD FEEDBACK FORM
Name of Patient ………………………………………………
AGE: ……………….. SEX: …………………… TODAY’S DATE: ………………………..
1. Waiting Time at Reception.
a. < 20mins b. < 30-45mins c. >60mins
2. Promptness / Attention of hospital staff
a. Poor b. Average c. Satisfactory d. Good
3. Level of hygiene maintained.
a. Poor b. Average c. Satisfactory d. Good
4. Waiting time of treating doctors of First consultation.
< 20mins b. < 30-45mins c. >60mins
5. Is the waiting area of the hospital comfortable?
[Link] b. Average c. Satisfactory d. Good
6. Waiting Time for X-ray Investigation
a. < 20mins b. < 30-45mins c. >60mins
6. Waiting time for Laboratory investigation
< 20mins b. < 30-45mins c. >60mins
7. Are you satisfied
a. Cleanliness of hospital YES NO
b. Doctors Behavior YES NO
c. Overall staff Behavior YES NO
We thank you for providing your valuable feedback which will help to
improve our quality.
Any Suggestions or Feedback :
Action Taken Signature of
officer
