Are you a new patient?
Yes No
What health service did you use?
General Checkup Surgery Emergency Care Consultation
How was your initial experience?
Excellent Good Average Poor
How likely are you to recommend us?
Very Likely Likely Unlikely Very Unlikely
How was the staff professionalism?
Very Professional Professional Neutral Unprofessional
How was the facility’s cleanliness?
Very Clean Clean Acceptable Dirty
All set, how can we reach you?
Name
Email
Phone
(Details here)
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