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Ebsar Alnoor Foundation Saudi institute for health services

Patient Satisfaction Form

Name:*

Age:

Address:*

Nationality:

Email:*

Phone:*

Job

Physician

File Number:

Hospital/Center:

Dep:*

Eye

ENT

Dental

Appointment before visit

Yes

No

Visit Time

(1-9) AM

(5-9) PM

How did you hear about us?

Newspaper

Other Physician

Repeated Visit

TV Advertisement

Radio

Suggested By Others

Patient Satisfaction Form

1- Ease to get an appointment by phone

2- Operator dealing with your telephone call

3- Ease to reach the hospital or center place

4- Parking

5- Communication with the reception staff

6- Ease to take appointment with your doctor

7- Waiting time to meet your doctor

30M-45M

45M-1H

1-1.30

More than 2H

Excellent

Good

Fair

Bad

Comments

Patient Satisfaction Form

8- Cooperation of nursing staff

9- Physician attitude

10- Understanding your medical case

11- Time spent with your physician

12- Doctor explained how to use medicines

13- Price and service quality relationship

14- possibility to repeat the visit when needed

Excellent

Good

Fair

Bad

Comments

Patient Satisfaction Form

What did you like the most?

What did you dislike the most?

Any suggestions?

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