Name of Patient: * Gender: Age:
Name of Client (if different from Patient): Type of Service:
Address:
Contact No: E-mail: *
At Love On Wheels Healthcare Services Sdn. Bhd., we are continuously striving to improve our services. Your valuable feedback in the form below will help us focus our efforts in the right direction. Thank you for your time and effort.This document will be handled with the utmost confidentiality.
  OUR SCALE IS AS FOLLOWS
1 = Poor 2 = Satisfactory 3 = Good 		  Remarks
1 Did the following personnel attend to you in a timely manner? Kindly rate each of these.
  (a). Love on Wheels Administrative Personnel
  (b). Love on Wheels Healthcare (Clinical) Personnel
2 Was our healthcare personnel attentive to your healthcare needs? Kindly rate this.
3 Was our healthcare personnel efficient and professional in providing our treatment or services? Kindly rate this.
4

How would you rate the benefits you gained from our mobile healthcare service in terms of the following:
  (a). Time Cost
  (b). Improving Health Status
  (c). Convenience
5 How likely is it that you would recommend us to your friends or colleagues?
(0=least likely 10=definitely) Kindly circle your number.
6 Can we share your testimonial below on our website? (Your personal information will not be disclosed)
7 Can we use your name on this testimonial   ( If No, kindly state your preferred alias  )  
 
 
Testimonial: