Feed back form Date of Visit: Name Contact Number Type of Treatment Received —Please choose an option—PanchakarmaRejuvenation TherapySpecific Treatment (e.g., Back Pain, Joint Pain)Others (Please specify) Section 1: Feedback on the Doctor Overall Satisfaction with the Doctor Very SatisfiedSatisfiedNeutralDissatisfied Doctor’s Knowledge and Expertise ExcellentGoodAveragePoor Doctor’s Communication and Explanation of Treatment Very ClearClearSomewhat ClearNot Clear Trust in the Doctor’s Treatment Approach Strongly TrustTrustNeutralDo Not Trust Additional Comments about the Doctor Section 2: Feedback on the Staff Friendliness and Courtesy of the Staff Very FriendlyFriendlyNeutralUnfriendly Professionalism and Competency of the Staff ExcellentGoodAveragePoor Timeliness and Efficiency of Service Very TimelyTimelySome DelaysSignificant Delays Responsiveness to Patient Needs Very ResponsiveResponsiveNeutralUnresponsive Additional Comments about the Staff Section 3: Feedback on the Hospital and Premises Cleanliness and Hygiene of the Facility Very CleanCleanAverageNeeds Improvement Comfort of the Waiting Area Very ComfortableComfortableNeutralUncomfortable Availability and Quality of Amenities (e.g., washrooms, drinking water) ExcellentGoodAveragePoor Ease of Navigation and Signage within the Facility Very EasyEasyModerateDifficult Overall Ambience and Environment of the Premises Very PleasantPleasantNeutralUnpleasant Additional Comments about the Hospital and Premises Section 4: Overall Experience and Suggestions Overall Satisfaction with the Visit Very SatisfiedSatisfiedNeutralDissatisfied Likelihood to Recommend Anzee Ayurveda Health Care Center Definitely WillProbably WillNot SureWill Not Recommend Additional Suggestions for Improvement
