INPATIENT SATISFACTION SURVEY FORM

... because we truly value your opinion, may we request you to answer this survey...

Is this your first time in our facility? *

Yes No

If Yes, how did you hear about us?

Social Media Family/Friend's Recommendation Others, please specify

GENERAL SATISFACTION

Please check the appropriate rating:
(Paki tsekan ang tamang marka)

3 - Highly Satisfied 2 - Satisfied 1 - Not Satisfied

Attending Physician *(Doktor)

123

Interaction with the Staff *(Pakikipag ugnayan sa mga empleyado)

123

Services of Staff *(Serbisyo ng Empleyado)

123

Quality of Facilities *(Kalidad ng Pasilidad)

123

Cleanliness of the Hospital *(Kalinisan sa Ospital)

123

ANCILLARY DEPARTMENTS

3 - Highly Satisfied 2 - Satisfied 1 - Not Satisfied

Cardio-Pulmonary Department *

123

Laboratory Department *

123

Radiology Department *

123

Rehabilitation Department *

123

Pharmacy *

123

Dietary Department *

123

FINANCE DEPARTMENT

3 - Highly Satisfied 2 - Satisfied 1 - Not Satisfied

Billing Section *

123

Cashier Section *

123

PhilHealth Section *

123

Social Service *

123

NURSING SERVICE DEPARTMENT

3 - Highly Satisfied 2 - Satisfied 1 - Not Satisfied

Dialysis *

123

Emergency Room *

123

ICU *

123

NICU/PICU *

123

Ward *

123

OR/DR *

123

Ambulance *

123

ADMINISTRATION

3 - Highly Satisfied 2 - Satisfied 1 - Not Satisfied

Information & Admitting *

123

Medical Records Department *

123

HMO *

123

Safety & Security *

123

OVERALL SATISFACTION

Are you satisfied with our services? * (Kuntento ba kayo sa aming serbisyo)

3 - Highly Satisfied 2 - Satisfied 1 - Not Satisfied

1 2 3

Would you recommend AMSI Doctors Medical Center to others? * (Mairerekumenda niyo ba ang AMSI Doctors Medical Center)

Yes No

If no, why not? (Kung hindi, bakit?)

Comments / Suggestions * (Puna / Mungkahi)

PATIENT INFORMATION

Patient Name

Contact Number

Address

Email Address

Age

Date Admitted

Attending Physician

Data Privacy Consent

In compliance with the Data Privacy Act of 2012 (Republic Act No. 10173), AMSI Doctors Medical Center is committed to protecting and respecting your privacy. The personal information collected in this survey will be used solely for the purpose of improving our healthcare services and patient experience. Your responses will be kept confidential and will not be shared with any third party without your explicit consent. By checking the box below, you acknowledge that you have read, understood, and agree to the collection, processing, and storage of your personal data as described herein.

I have read and agree to the Data Privacy Consent *

AMSI Doctors Medical Center - Inpatient Satisfaction Survey