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RUMAH SAKIT MARGANINGSIH

Jl. Raya Purwodadi - Blora KM. 5 RT.001 RW 003


Rejosari Grobogan Jawa Tengah, 58152
Telp/fax 0292-426 275, Hp 082 138 167 551
E-mail : kxmarganingsih@gmail.com

ANGKET KEPUASAN PELAYANAN AMBULANCE/ MOBIL JENAZAH

Hari : ............................................. Tanggal : ........................ Jam


: .........................

Plat Nomor : ........................................

Identitas Pemesan Kendaraan


Nama : ....................................................

Alamat : Desa/Kel :.................................................. RT.......... RW............... Kec. ....................


No. Telpon : ......................................................

Identitas Pasien

Nama Pasien : .....................................

Bangsal/ Ruang :......................................

No. Register :......................................

Status Pelayanan : .....................................

Beri Tanda Cormet ( V atau X )

No Kegiatan Puas Tidak Puas


1 Senyum, Salam, Sapa
2 Kenyamanan Pengemudi
3 Komunikasi Pengemudi
4 Wawasan Pengemudi Terhadap Rute/ Daerah
5 Kenyamanan Kendaraan

Usul dan Saran :


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Keluarga Pasien Pengemudi / Pengantar


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