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

   Multiphasic Health Screening Service

   Changi Sports Medicine Centre

   Endoscopy Suite

   Geriatric Day Hospital/Clinic

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
What is your overall satisfaction with CGH? *

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.