Pramod Dental & Oro-Maxillofacial Clinic

(Pramod Dental & Oro-Maxillofacial Clinic)
Center for Advanced Dentistry, Dentofacial Trauma, Deformities and Dental Implants

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Appointment Request

Feedback Form

Dear friend,

By filling and sending us the feedback form given below, you are contributing to improving our services to you.

Hence, please take a few seconds of your valuable time to fill in the form and send us the same.

Please note that only registered patients of Pramod clinics (Valanjambalam & Narakkal) and of the Dental & Faciomaxillary Dept., Saraf Hospital, need fill this form (you would have been allotted an OP no: which is noted in the OP card provided to you at the time of registration).

Best wishes,
Dr. Prasanth Pillai
drprasanth@pramodclinic.com

1) How did you report to this clinic for treatment, the first time ? (kindly tick appropriately)

Seeing the Clinic board
Referred by another patient / person who has visited this clinic
Seeing the clinic advertisement - eg. Yellow Pages, Hello Cochin etc.
Via Internet
Referred by a doctor Name Dr Specialty
Other means (please specify)

2) Did you understand clearly about the dental and related problems you have/had and about the treatment procedures performed on you ? Yes No

3) Did you experience problems while undergoing treatment? Yes No

4) Kindly fill these columns appropriately:

Please select appropriately					Remarks if any
Service	Poor	Satisfactory	Good	Excellent	Remarks if any
Reception
Behavior and attitude of staff
Behavior and attitude of doctors
Promptness in service
Facilities
Treatment provided
General clinic arrangements & set-up
Cleanliness of the clinic and surroundings

5) Are you aware of the various treatment facilities offered by this clinic ? Yes No

6) What do you feel about the professional fees being collected towards treatment and allied services in our clinic ?

Low Moderate Excessive

7) Your suggestions on our website.

We welcome your suggestions on how we can improve our services.

SUGGESTIONS:

Your Name:
Address:
Telephone:
Email:
Pramod Clinic / Saraf Hospital - OP No:

Thank you for spending your valuable time to complete this
questionnaire.
We look forward to serving you even better.