5 4 3 2 1

OF URDANETA
Medical Services 3. Were the charges Service
Reasonable? Facility
5 4 3 2 1
a. Doctor’s Fee Doctors
1.Did your physician visit
you regularly
2.Was your physician
b. Hospital BillReferred by Doctors
Referred by Former Patient INC. HOSTIPAL
available when needed Nearest Hospital
3.Were your questions #25 High School Drive, San Vicente West, Urdaneta
Overall impression of the Divine Mercy Foundation of City, Pangasinan.
answered satisfactorily by Urdaneta Hospital Service:
your physician Tel. No: (075) 656-2103
Other Services Excellent Cp No.: 09175002025
5 4 3 2 1 Very Good
1.Maintenance, Lobby Good
2.Security Fair
3.Canteen Need Improvement
4.Ambulance Comments/Suggestions
5.Ultrasound ___________________________________________
6.Laboratory, X-Ray ___________________________________________
7.OPD ___________________________________________
8.Pharmacy ___
9.Billing Name of Person doing this survey
10.Operating Room/ ____________________________________________
Delivery Room Name of Patient/ Watcher
___________________________________________
Your Bill
5 4 3 2 1 Signature ___________________________________
1.Is your Statement of

DIVINE MERCY
Account (SOA) properly
explained? WE APPRECIATE YOUR
2.Was the billing
FEEDBACK TO US!
personnel:
a. Courteous? FOUNDATION Dear Patient
b. Prompt?
What made you choose Divine Mercy Foundation of Welcome to the Divine Mercy Foundation of
Urdaneta Hospital for your hospitalization? Check one Urdaneta Hospital!
or more
 We are glad to be of service to your health and 4 – VERY GOOD b. Changed regularyly?
well - being! 3 – GOOD
Kindly help us improve more of our services 2 – FAIR YOUR FOOD
by taking your time to answer this survey.
1 – NEEDS IMPROVEMENT 5 4 3 2 1
We are very grateful for your cooperation and
we hope you have exceptional and pleasant hospital 1. Warm
stay in our institution. ADMISSION 2. Attractive and
5 4 3 2 1 appetizing
Important: 1. Was the admitting 3. Served on time
If you have concerns or complaint/s that procedure:
require/s immediate attention, please approach our 4. According to your
a. Prompt?
nurses, any hospital personnel or you may write them advised diet
b. Efficient?
here: c. Courteous?
____________________________________________ 2. Where your concern/s NURSING CARE
____________________________________________ attended to your 5 4 3 2 1
____________________________________________ satisfaction? 1. Did the Nursing
____________________________________________
Staff respond
____________________________________________
YOUR ROOM: promptly to your
ROOM NUMBER: ____ needs?
____________________________________________
Print Name and Signature / Date 2. Friendly?
5 4 3 2 1
3. Compassionate?
1. Was your room 4. Courteous?
General Information a. Kept clean? 5. Were question
b. Comfortable? related to your
Name:
____________________________________________ c. Quiet? confinement
2. Were the people who answered
Attending Physician: cleaned your room satisfactorily?
6. Were you visited by
a. Friendly?
____________________________________________ the Nurse On Duty
b. Courteous? frequently?
c. Efficient?
Please rate our services with the following rating
scale: 5 4 3 2 1
3. Was the linen
5 – EXCELLENT a. Clean?