Patient Rights Survey
Answers marked with a * are required.
 
1. Please enter your name
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2. Are you filling up this survey as your own experience or on behalf of somebody else?
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3. Your contact e-mail ads
 
 
 
4.

In  which of the following hospitals have you or your relative received treatment in the past year?

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Other (Please Specify)
 
 
 
5. Please provide the name of the patient and date of admission
( Patient identity will be kept confidential. However information gathered from this survey will be used to improve observance of patient’s rights in hospitals from Pune city. )
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Name of Patient
Date of Admission
Duration of Admission
 
 
 
 
 

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