Please fill this feedback form based on your most recent interaction with the doctor and from the perspective of the patient.

You're filling this form as...

Which of the following reasons best describes the reason for your visit today? (please select all that apply)

Based on your experience today, how good was your doctor on each of the following parameters?

  Pathetic Poor Satisfactory Good Great
Being polite
Making you feel at ease
Listening to you
Assessing your condition
Explaining your condition
Discussing your treatment

Based on your experience today, how likely are you to recommend this doctor to your friends and family?

Not at all likely
Not at all likely Extremely likely
Extremely likely

Would you like to share any comments and suggestions about your experience today?