Patient Feedback form

In order to provide the best possible care and identify areas for improvement, we value your feedback on the service you received when a patient at South Perth Hospital. We would appreciate you taking the time to complete this survey. Your answers remain strictly confidential with our guarantee that the information will only be used to improve our services.

Patient name:

Admission Date:

Doctor's name:

Who is filling out this survey:

Patient

Family

Friend

Parent

What is the patients gender:

Male

Female

Age range: *

How many days was the patients most recent stay:

Please rate your satisfaction on a scale of 1-5 with five being the highest

How could we improve our service?:

General comments::

Occasionally, South Perth Hospital utilises Customer Focus Groups. Are you interested in participating? Please provide contact details.

Name:

Daytime phone number:

Email address (optional):

Thank you for assisting us to improve our services.

To all the Beautiful nursing staff, Just to say thank you. You are all a credit to the hospital and the nursing industry. Thank you for being the people you are and always working so hard to care for others.

September 2011

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