DON MEDICAL CLINIC - PATIENT FEEDBACK FORM
DATE:
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Please select Option
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Compliment
Suggestion
Complaint
First Name
Last Name
Email Address
Phone Number
Relationship to Patient
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Self
Spouse
Parent
Dependent Child
Legal Guardian
Compliment:
Quality of Medical Care
Staff Assistance/ Support
Caring & Compassionate
Friendly & Courteous Staff
Outstanding Customer Service
Timely Problem/ Issue Resolution
Superior Facilities
Other _____________________________________________________
SuggestionPlease feel free to make a suggestion about how we can improve our service to our patients
Complaint
Substandard Care (e.g. misdiagnosis; negligent treatment; delay in treatment; etc)
Unprofessional Conduct (e.g. breach of privacy; record alteration; provider impairment; etc)
Office Practice (e.g. inattentive; rude or abusive behavior; failure to adequately address patients needs; etc)
Substandard Facilities or Equipment (e.g. cleanliness concerns; cluttered; equipment inoperative; etc)
Scheduling or Appointment Issues (e.g. difficulty scheduling; not timely; etc)
Prescribing Issues (e.g. medication errors; over/under prescribing; failure to respond; etc)
Other: ______
Narrative Comments (please be as clear and concise as possible):
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Regarding this Comment, I wish to be contacted
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Yes
No
Our Practice manager will respond to your feedback
Filing a compliment or complaint is strictly voluntary. Information submitted on this form is treated confidentially. We Appreciate your time in completing this form
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