Patient Survey Form

PATIENT SURVEY FORM

As Istanbul Eye Hospital, we are deeply committed to the ideas and opinions of our valuable patients, patient relatives and visitors. You can communicate your impressions and ideas through this form with your sincere thoughts.

Name - Surname *

E-Mail *

Telephone Number

Profession

Is this the first time you have come to our hospital?

Yes

The unit you have visited:

Polyclinic

Examination / Treatment

Excimer Laser

Inpatient Treatment

Your reason for choosing our hospital:

That your hospital is known

That your physicians are known

Contracted institutions (Banks, private insurance or governmental agency)

On recommendation

That your hospital is close my home / my workplace

Evaluation

	Poor	Medium	Good	Very Good	Excellent
Your opinion about our appointment system	Your opinion about our appointment system - Poor	Your opinion about our appointment system - Medium	Your opinion about our appointment system - Good	Your opinion about our appointment system - Very Good	Your opinion about our appointment system - Excellent
Our waiting rooms are available to sit while waiting for an appointment	Our waiting rooms are available to sit while waiting for an appointment - Poor	Our waiting rooms are available to sit while waiting for an appointment - Medium	Our waiting rooms are available to sit while waiting for an appointment - Good	Our waiting rooms are available to sit while waiting for an appointment - Very Good	Our waiting rooms are available to sit while waiting for an appointment - Excellent
Time and implementation of your registration and payment processes	Time and implementation of your registration and payment processes - Poor	Time and implementation of your registration and payment processes - Medium	Time and implementation of your registration and payment processes - Good	Time and implementation of your registration and payment processes - Very Good	Time and implementation of your registration and payment processes - Excellent
General appearance, and physical conditions and cleanliness of the unit you have visited	General appearance, and physical conditions and cleanliness of the unit you have visited - Poor	General appearance, and physical conditions and cleanliness of the unit you have visited - Medium	General appearance, and physical conditions and cleanliness of the unit you have visited - Good	General appearance, and physical conditions and cleanliness of the unit you have visited - Very Good	General appearance, and physical conditions and cleanliness of the unit you have visited - Excellent
Overall quality of services of our physicians	Overall quality of services of our physicians - Poor	Overall quality of services of our physicians - Medium	Overall quality of services of our physicians - Good	Overall quality of services of our physicians - Very Good	Overall quality of services of our physicians - Excellent
Overall quality of services of our nurses	Overall quality of services of our nurses - Poor	Overall quality of services of our nurses - Medium	Overall quality of services of our nurses - Good	Overall quality of services of our nurses - Very Good	Overall quality of services of our nurses - Excellent
Attention and courtesy of our staff at the polyclinic	Attention and courtesy of our staff at the polyclinic - Poor	Attention and courtesy of our staff at the polyclinic - Medium	Attention and courtesy of our staff at the polyclinic - Good	Attention and courtesy of our staff at the polyclinic - Very Good	Attention and courtesy of our staff at the polyclinic - Excellent
Overall quality of services of our cafeteria	Overall quality of services of our cafeteria - Poor	Overall quality of services of our cafeteria - Medium	Overall quality of services of our cafeteria - Good	Overall quality of services of our cafeteria - Very Good	Overall quality of services of our cafeteria - Excellent
Cleaning and layout of our Examination/Patient rooms	Cleaning and layout of our Examination/Patient rooms - Poor	Cleaning and layout of our Examination/Patient rooms - Medium	Cleaning and layout of our Examination/Patient rooms - Good	Cleaning and layout of our Examination/Patient rooms - Very Good	Cleaning and layout of our Examination/Patient rooms - Excellent

Would you recommend our hospital to your relatives?

Yes

Your impression that you have acquired during your visit to our hospital

Your thoughts and suggestions

Other information you would like to send us

Leave this field blank

PATIENT SURVEY FORM

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