Fields marked with * are mandatory.

Contact Information

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Name of patient: Mr Miss Mrs Mdm

IC No: - -

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If you are not a patient of the hospital, please provide us with
your details.
Name: Mr Miss Mrs Mdm

IC No: - -

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Address:
Apt Blk / House No.       Unit No.
                  -
Street Name:

Postal code:
Tel No:
E-mail:

Place Of Visit

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Clinic *

A	B	C	D	E	F	G	H	S
J	K	L	M	N	P	Q	R	T

	A & E Department		Diabetes Centre
	Day Surgery		Dental Clinic
	Rehabilitation Services		Pharmacy
	Multiphasic Health Screening Service		Medical Records Office
	Changi Sports Medicine Centre		Clinical Measurement Unit
	Endoscopy Suite		Musculoskeletal Physiotherapy Clinic
	Geriatric Day Hospital/Clinic		Radiology Department (X-Ray)

Please rate your level of satisfaction by ticking
the appropriate box:

Counter Staff

		Excellent	Good	Satisfactory	Poor	Very Poor
Courtesy
Competence

Outpatient Service

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Nursing Staff

		Excellent	Good	Satisfactory	Poor	Very Poor
Care & Concern
Knowledge & Skills

Medical Staff

		Excellent	Good	Satisfactory	Poor	Very Poor
Care & concern
Clarity of Explaination
Knowledge & Skills

Other Services

		Excellent	Good	Satisfactory	Poor	Very Poor	N.A.
X-ray Services
Rehabilitation
Pharmacy Services
Clinical Measurement Unit
Medical Social Services
Medical Records Office
Hospital Facilities & Equipment
Cleanliness of the Hospital Facilities

		Excellent	Good	Satisfactory	Poor	Very Poor
Smooth co-ordination of care *

		Excellent	Good	Satisfactory	Poor	Very Poor
Rate your overall satisfaction with CGH? *

Based on your current experience, would you recommend this hospital to your friends if they should fall ill?

Strongly Recommend	Likely to Recommend	Unlikely to Recommend	Will not Recommend	Neutral

Do you wish to compliment any staff for outstanding care and services?


Please share your experience at the hospital with us and any suggestions on how we can further improve our services.