AMSI Doctors Medical Center

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OUTPATIENT SATISFACTION SURVEY FORM

Your opinion matters! Please take a few minutes to rate us to serve you better.

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

VISIT DETAILS

Department Visited *

What services / procedures did you avail? *

OVERALL SATISFACTION

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

Yes No

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 of Visit

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 - Outpatient Satisfaction Survey