| You are our * |
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| How did you hear about us? * |
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| You were our patient as * |
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| Your treating physician |
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| Name of the patient * |
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| City |
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| Email ID * |
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| Phone Number |
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| Mobile Number |
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| HH No * |
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| Which is the most important criteria in deciding an hospital? * |
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| Rate our specialists (attention to you, personalized care, promptness of treatment, quality of care) * |
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| Rate our services (promptness of care, courtesy, pleasantness) * |
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| How satisfied are you with the competency of our staff? * |
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| Rate your overall experience * |
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| We need to improve upon * |
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| We impressed you with * |
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| Our star performer (any employee you would like to mention for his/her exceptional attitude and performance) |
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| Any other comments |
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| Would you recommend us to others? * |
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| How would you rate us compared to other health facilities you have visited? * |
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