Patient Feedback Form

Patient Name

MRD No

Ward/Room No

Doctor Select Ajith S Ann Jacob Mary Ansar P P K B Rjamma Saneesh J(GGH) P Jayakrishnan S Sajith S J Janardhanan Potty Unnikrishnan S Ramiz Raja Prabhakaran Nair Tittu Oommen Prem R Krishnan Gini K A Pooja Korath Vijaya Amma Lekshmy K Raman Nair N Akhila Mohan Nikhil G Manoj P Sulphi Abdul Basheer Arun B Liji Viincent Brahma B L Lakshmi Praveen A Jigy Joseph Radhika K Mohan Shenoy T Anjana Varrier G V K Sreekala Kiran Raj V Rameshwara Talya Rakul Nambiar Benny PV K Mahadevan SHASHIKIRAN M S Jayakumar C Angel Mary Sam Sreekanth S K Samadarsi P Ansar P P Abhilash TP Nair Raffic Geetha O Susheela Anilkumar Vivek George Resmi Rajan Usha Devi R S N Roy Nandini V R Preeja C V Suja Mathen P George Shenoy T K ASWATHY S Dayananda Babu Lekshmi G S Ramani P T Gayathri Madhu Sasikumar K Aravind Ajid Abhijith G Jayachandran Manju S K Harikumaran Nair G S Binu S S Kurshid M V Arunkumar L M Anil Bindu S Lalitha Kailas Anila Tresa Alukal Saji Radhakrishnan Nair Vidyadhara Gupta Prasad Shobha P Venugopalan P G K B Rajamma Abeer Abdul Rezak Simi S M Sulekha Devi P B Anoop R Seethal Jose AISHWARYA S Gayatri Gopan Beenakumari R Sreekanth K S Sheela Vasudevan Jini Bhuvanendran Jineesh Joseph Bindu Thampi Ajith V Messaline Sunitha Nini Navakumar Nidhin R Amritalal . Devika Sunil Kiranjith J Regi Jose Aswathy Sundaresh Manojan K K Mamata Chimmalgi Shaila S Krishna G Beena Thomas Jithin Jacob Manju K S Umar MMA Shareef Rupa Sreedhar Devan Prakash Sugandha K R Amritha Prasad Nishant M B Thanseer . Geetha S Neethu P T Nazeema Beevi Amita A T Swapna K Pillai Anil Roby D Sumesh Raj Anand Sekhar Visakh Prasad Linu M S Shafeeque Shaikh Shaji S M Remya R Nirmal George Abhilash A Abdul Arafath P Kumar V K Sajitha N Henry P Y Kalaranjini K V Resmi K Arathy R Aswathy Sundaresan Nimmy P V Pavithran Reshma Sugathan Razin Nazarullah Divija Sumesh Raj Deepthi T Suhana N J Archana Pillai R Sheeja G Rakhil K S Rekha R S Swapna C Senan Shabana Thaha J Jithin J Rijuta priti Keba J Vivek Oommen Varghese Suja Daniel Smitha H Beegam Shoufi Kunjumon Sreeja Babu C Krishnan K Arun Sivadas Poornima Pavithran krupa Krishnakumar Thomas K Thomas Asha U V Nitheesh C Manju L Jinu Abraham Glaxon Sukshma Sasidharan Bini Balakrishnan Ajeena A J Satheesh Kumar S Andra Easwar Kumar Vijayakumary B Rekha S Nair Elizabeth Jacob Dhanya T Manish Mohan M Aswathy Chandramohan Kiran Subhash Neelima V Nair Sunantha Kumari L T Anupama Shaji Sonia M Lal Vandana Viswakumar Nishana Shoukath Ali Karthika Rajeev Arun Edwin Raju G Ramu R J Nabeel Sajudeen Rajan J Nithin Varghese Abraham Susanna John Anoop S Manjusha Viswanathan Kiran Rajagopal. Chinchu Chandran Narayanan S K Rithwik Rajeev K Praveen Kesav R Ajith Kumar P V Bharat Chandra K Akhila V Sony S Abhi Chandran Ajayan G Grace Ravindran Ivy Abraham Varghese Lekshmi M Nisha Bhaskar Sruthy Mohan Swathi Vijayan Divya Prasad R Subhash R Kurup Aswathy M Pillai Sathchith S Aditi Suseelan Amritha Mathew Kavitha K P Kala S N Yedudev B S Amal Prasad Sanjay Zachariah Nand Kishore A Vitni Fernz Prameeda P R Jojo Joseph Antony HARSHA LAIS Poornima Vijay Tissa John Himiki S Ashna Ajimsha Anjana B Raj Hijaz Ahamed N Rino Rakesh Bhavani Nair L Neetha Babu Anu V Babu Lency S Kuriakose Sonu Sabu SWATHY A Smitha Kiran Shinu S Aradhana Radhakrishnan Shilpa Prakash Adarsh S Nair Ambikapathi P Minu Gopi Rugma R Reshma O R R K Prabhu Swaroop Sujith Anupama B S Arun Prasath Paul Nirmala Stanly Vishnu K S Akhila Naz Arunlal Devi Vidhyadaran Arathi Raj S B Shruthi Surendran Aiswarya Ghosh
 Praveena K P Mahima S M ALEENA KHAN MOHAMMED SAJAS Jesmy Chacko Harsha Devi S
 Anupama Devi P Sreedevi V S Jarlin John Malavika Gopi Parvathy Vijay Sana Majeed Anila Tresa Alukal Veena M Pillai JYOTHISH S S Prasanth Prasad Reshma Reji Pooja Nair Arsha M Dev Farhana Jabbar S Ajmi RIYA S Karthika S Nitha P Anil Hrudya Venugopal Rose Mary Varghese Roshna R S Jayashalini M Sini Christy Christhudasan GOURI M Shilpa Krishna Mariya Jacob Anjali Vijayan Arya A Navya M S Tini Prem Santheev . Anu Y S Tony P Joseph Megha . Hasna Ibrahim Arya J S Rajeesh R Nair Keerthi S Hima M NEETHU P.T Jijo Ansari Sreelekshmi S Rahul Suresh Snigdha B S Sija Chandran Sumi J S Aravind D NEENU V G Madiha Abdul Majeed Abdul Nazer ARYA RAJAGOPAL Suvya Surendran Devu Dilip Jayadeep R Aarcha Mohan Preema Paul Neeraja C K Ann Mary Babu Rani S Rajan Devi V S Jeffy Jacob Praveena S. Kiran N

Admission Date

Discharge Date

Reason for Discharge Select On advice by doctor Permanent cure impossible Financial Reason Need better treatment Not satifified with treatment recieved Others

Overall assessment of treatment recieved from here Select Excellent Good Satisfactory Poor

Reason for assessment

Please tick the appropriate response

	Excellent	Good	Satisfactory	Poor
Doctors
Nursing
Pharmacy
Laboratory
Scanning - X-ray/Ultrasound/CT/MRI etc.
Reception/Admission
Billing
Public Relations
Service by Attenders
Security Service
Facilities in the room/ward
Canteen
Hospital Cleanliness
Insurance helpdesk Service, if applicable
Casualty Service, if applicable

Mention the departments where you recieved delayed service,if any

Time taken for discharge process Select < 2 hrs < 3 hrs > 3 hrs

Did the sign boards in here help you in reaching destination Select Yes No

Mode of admission Select Direct Referred By Advertisement Schemes/TPA/Corporate

Are you satisfied with the overall service recieved from here Select Yes No

Any suggestion to improve our service

Name of responder

Contact Number

SUBMIT