Customer Satisfaction Survey

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1 Step 1

This survey will only take 5 minutes to complete.

Patient's NamePatient's full name

Your Nameyour full name

Dateof appointment

How much do you agree with the following statements?

4 = Strong Agree, 3 = Agree, 2 = Disagree, 1 = Strong Disagree

EnquiringFill in where applicable

	4	3	2	1
It was easy for me to obtain information I needed through RasaCare’s website/brochure/other collaterals.
The nursing advice given over the phone was useful and clear.

Service Activation

	4	3	2	1
The staff I corresponded/spoke with was friendly and polite.
The person attending to my call/messages was informative and attentive.
It was easy for me to book an appointment with RasaCare.
Overall, I am satisfied with the service of the office staff.

Nursing Service

	4	3	2	1
The nurse provided clear explanation and information on the procedure.
The nurse was approachable; I felt comfortable talking to the nurse.
The nurse gave me assurance and did her/his best to bring comfort to the patient.
The nurse was clean and hygienic during the procedure.
The nurse guided me and provided me options/alternatives of care for the patient.
Overall, I am satisfied with the service provided by the nurse.

What was done particularly well during the home visit by the nurse?

0 /

What are areas for improvement (especially if you indicated ‘disagree’ or ‘strongly disagree’ on any of the above fields)?

0 /

Do you wish to compliment any nurse and/or staff?

0 /

Thank you for your valuable feedback!

	4	3	2	1
The instructions for payment were clear.
It was easy for me to complete the payment process.

	1	2	3	4	5
How likely are you to engage RasaCare again if required?
How likely would you recommend RasaCare to someone else?