Celyxmed
Clinic
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Patient Satisfaction Survey
Feedback Form
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Guest Information
Date *
Phone *
Full Name *
E-mail
Age
Education Level
Country
Gender
Female
Male
Filled By
Patient
Patient's Relative
Provided Healthcare Service
Plastic Surgery
Medical Aesthetics
Hair Transplant
Dental Aesthetics
Other:
Initial Welcome
Evaluation Criteria
Very Poor
Poor
Average
Good
Excellent
Transfer service
Very Poor
Poor
Average
Good
Excellent
Clinic welcome and guidance
Very Poor
Poor
Average
Good
Excellent
Patient consultant's attention
Very Poor
Poor
Average
Good
Excellent
General Clinic View
Evaluation Criteria
Very Poor
Poor
Average
Good
Excellent
Cleanliness of Exam/Procedure Rooms
Very Poor
Poor
Average
Good
Excellent
General cleanliness and order
Very Poor
Poor
Average
Good
Excellent
Comfort and atmosphere of the clinic
Very Poor
Poor
Average
Good
Excellent
Respect for privacy and personal rights
Very Poor
Poor
Average
Good
Excellent
Consulting and Information
Evaluation Criteria
Very Poor
Poor
Average
Good
Excellent
Waiting time
Very Poor
Poor
Average
Good
Excellent
Adequacy of info about the treatment process
Very Poor
Poor
Average
Good
Excellent
Appointment planning and organization
Very Poor
Poor
Average
Good
Excellent
Clarity of pricing and payment processes
Very Poor
Poor
Average
Good
Excellent
Translator/Language support (if any)
Very Poor
Poor
Average
Good
Excellent
Physician Services
Evaluation Criteria
Very Poor
Poor
Average
Good
Excellent
Physician's attention
Very Poor
Poor
Average
Good
Excellent
Time allocated by the physician
Very Poor
Poor
Average
Good
Excellent
Trust in the physician's expertise
Very Poor
Poor
Average
Good
Excellent
Adequacy of post-treatment information
Very Poor
Poor
Average
Good
Excellent
Overall Conclusion & Comments
What did you like most about our clinic?
Areas for Improvement
Additional Comment/Suggestion
Generally satisfied?
Very Poor
Excellent
Recommend us?
Yes
No
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