{"id":24060,"date":"2026-08-12T10:11:23","date_gmt":"2026-08-12T03:11:23","guid":{"rendered":"https:\/\/abdiwaluyo.com\/patient-satisfaction-survey\/"},"modified":"2026-08-12T10:48:59","modified_gmt":"2026-08-12T03:48:59","slug":"patient-satisfaction-survey","status":"publish","type":"page","link":"https:\/\/abdiwaluyo.com\/en\/patient-satisfaction-survey\/","title":{"rendered":"OUTPATIENT SATISFACTION SURVEY"},"content":{"rendered":"<div class=\"container mt-4\">Choose Language : \n<div role=\"navigation\" aria-label=\"Language Switcher\" class=\"wpml-ls-statics-shortcode_actions wpml-ls wpml-ls-legacy-dropdown-click js-wpml-ls-legacy-dropdown-click\">\n\t<ul>\n\n\t\t<li class=\"wpml-ls-slot-shortcode_actions wpml-ls-item wpml-ls-item-en wpml-ls-current-language wpml-ls-first-item wpml-ls-item-legacy-dropdown-click\">\n\n\t\t\t\t\t\t\t\t\t<a href=\"#\" hreflang=\"en\" lang=\"en\" class=\"js-wpml-ls-item-toggle wpml-ls-item-toggle\" aria-current=\"page\" aria-expanded=\"false\" aria-controls=\"wpml-ls-submenu-click-default\" aria-haspopup=\"true\" aria-label=\"English \u2013 Language switcher, click to open then tab to navigate\" tabindex=\"0\" role=\"button\" title=\"Switch to English\">\n\t\t\t\t                                    <img decoding=\"async\"\n            class=\"wpml-ls-flag\"\n            src=\"https:\/\/abdiwaluyo.com\/wp-content\/plugins\/sitepress-multilingual-cms\/res\/flags\/en.png\"\n            alt=\"\"\n            loading=\"lazy\"\n            width=18\n            height=12\n    \/><span class=\"wpml-ls-native\">English<\/span><\/a>\n\n\t\t\t<ul id=\"wpml-ls-submenu-click-default\" class=\"js-wpml-ls-sub-menu wpml-ls-sub-menu\">\n\t\t\t\t\n\t\t\t\t\t<li class=\"wpml-ls-slot-shortcode_actions wpml-ls-item wpml-ls-item-id wpml-ls-last-item\">\n\t\t\t\t\t\t<a href=\"https:\/\/abdiwaluyo.com\/\" hreflang=\"id\" lang=\"id\" class=\"wpml-ls-link\" aria-label=\"Switch to Indonesian\" title=\"Switch to Indonesian\">\n\t\t\t\t\t\t\t                                    <img decoding=\"async\"\n            class=\"wpml-ls-flag\"\n            src=\"https:\/\/abdiwaluyo.com\/wp-content\/plugins\/sitepress-multilingual-cms\/res\/flags\/id.png\"\n            alt=\"\"\n            loading=\"lazy\"\n            width=18\n            height=12\n    \/><span class=\"wpml-ls-display\">Indonesian<\/span><\/a>\n\t\t\t\t\t<\/li>\n\n\t\t\t\t\t\t\t<\/ul>\n\n\t\t<\/li>\n\n\t<\/ul>\n<\/div>\n<\/div>\n<div class=\"container mt-4\">\n<div class=\"card shadow-sm\">\n<div class=\"card-header text-white\" style=\"background-color: #00549f;\">\n<h5 class=\"mb-0\">Outpatient Questionnaire<\/h5>\n<\/div>\n<div class=\"card-body\">\n<div id=\"quform-d564b3\" class=\"quform quform-25 quform-theme-bootstrap quform-support-page-caching\"><form id=\"quform-form-d564b3\" class=\"quform-form quform-form-25\" action=\"\/en\/wp-json\/wp\/v2\/pages\/24060#quform-d564b3\" method=\"post\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-options=\"{&quot;id&quot;:25,&quot;uniqueId&quot;:&quot;d564b3&quot;,&quot;theme&quot;:&quot;bootstrap&quot;,&quot;ajax&quot;:true,&quot;logic&quot;:{&quot;logic&quot;:[],&quot;dependents&quot;:[],&quot;elementIds&quot;:[],&quot;dependentElementIds&quot;:[],&quot;animate&quot;:true},&quot;currentPageId&quot;:1,&quot;errorsIcon&quot;:&quot;&quot;,&quot;updateFancybox&quot;:true,&quot;hasPages&quot;:false,&quot;pages&quot;:[1],&quot;pageProgressType&quot;:&quot;numbers&quot;,&quot;tooltipsEnabled&quot;:true,&quot;tooltipClasses&quot;:&quot;qtip-quform-dark qtip-shadow&quot;,&quot;tooltipMy&quot;:&quot;left center&quot;,&quot;tooltipAt&quot;:&quot;right center&quot;,&quot;isRtl&quot;:false,&quot;scrollOffset&quot;:-50,&quot;scrollSpeed&quot;:800}\"><button class=\"quform-default-submit\" name=\"quform_submit\" type=\"submit\" value=\"submit\" aria-hidden=\"true\" tabindex=\"-1\"><\/button><div class=\"quform-form-inner quform-form-inner-25\"><input type=\"hidden\" name=\"quform_form_id\" value=\"25\" \/><input type=\"hidden\" name=\"quform_form_uid\" value=\"d564b3\" \/><input type=\"hidden\" name=\"quform_count\" value=\"1\" \/><input type=\"hidden\" name=\"form_url\" value=\"https:\/\/abdiwaluyo.com\/en\/wp-json\/wp\/v2\/pages\/24060\" \/><input type=\"hidden\" name=\"referring_url\" value=\"\" \/><input type=\"hidden\" name=\"post_id\" value=\"\" \/><input type=\"hidden\" name=\"post_title\" value=\"\" \/><input type=\"hidden\" name=\"quform_current_page_id\" value=\"1\" \/><input type=\"hidden\" name=\"quform_loaded\" value=\"1787773723|ffceb69042e375741e6baf264f6fdf9f\" \/><input type=\"hidden\" name=\"quform_csrf_token\" value=\"pdyjozD5fAe6PJRvTTFQibkxMKLjHF1q2YWNkHOK\" \/><div class=\"quform-elements quform-elements-25 quform-cf quform-responsive-elements-phone-landscape\"><div class=\"quform-element quform-element-page quform-page-1 quform-page-25_1 quform-cf quform-group-style-plain quform-first-page quform-last-page quform-current-page\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-group quform-element-25_6 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><\/div><\/div><\/div><div class=\"quform-element quform-element-html quform-element-25_5 quform-cf\"><div class=\"quform-spacer\"><h3 style=\"color: green;\">INSTRUCTIONS FOR COMPLETION<\/h3>\nPlace a checkmark in the box (\u25cb) that best corresponds to your experience.<\/div><\/div><div class=\"quform-element quform-element-group quform-element-25_21 quform-cf quform-group-style-plain\"><div class=\"quform-spacer\"><div class=\"quform-child-elements\"><div class=\"quform-element quform-element-row quform-element-row-25_22 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_23\"><div class=\"quform-element quform-element-radio quform-element-25_26 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_26\"><label class=\"quform-label-text\" id=\"quform_25_26_d564b3_label\">Our hospital's physical facilities\u2014encompassing cleanliness, comfort, and the completeness of facilities..<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-25_26\"><div class=\"quform-input quform-input-radio quform-input-25_26 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_25_26_d564b3_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_26\" id=\"quform_25_26_d564b3_1\" class=\"quform-field quform-field-radio quform-field-25_26 quform-field-25_26_1\" value=\"Very Satisfied\" \/><label for=\"quform_25_26_d564b3_1\" class=\"quform-option-label quform-option-label-25_26_1\"><span class=\"quform-option-text\">Very Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_26\" id=\"quform_25_26_d564b3_2\" class=\"quform-field quform-field-radio quform-field-25_26 quform-field-25_26_2\" value=\"Satisfied\" \/><label for=\"quform_25_26_d564b3_2\" class=\"quform-option-label quform-option-label-25_26_2\"><span class=\"quform-option-text\">Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_26\" id=\"quform_25_26_d564b3_3\" class=\"quform-field quform-field-radio quform-field-25_26 quform-field-25_26_3\" value=\"Neutral\" \/><label for=\"quform_25_26_d564b3_3\" class=\"quform-option-label quform-option-label-25_26_3\"><span class=\"quform-option-text\">Neutral<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_26\" id=\"quform_25_26_d564b3_4\" class=\"quform-field quform-field-radio quform-field-25_26 quform-field-25_26_4\" value=\"Dissatisfied\" \/><label for=\"quform_25_26_d564b3_4\" class=\"quform-option-label quform-option-label-25_26_4\"><span class=\"quform-option-text\">Dissatisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_26\" id=\"quform_25_26_d564b3_5\" class=\"quform-field quform-field-radio quform-field-25_26 quform-field-25_26_5\" value=\"Very Dissatisfied\" \/><label for=\"quform_25_26_d564b3_5\" class=\"quform-option-label quform-option-label-25_26_5\"><span class=\"quform-option-text\">Very Dissatisfied<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-25_31 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_32\"><div class=\"quform-element quform-element-radio quform-element-25_33 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_33\"><label class=\"quform-label-text\" id=\"quform_25_33_d564b3_label\">The reliability of our officers and staff in serving you.<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-25_33\"><div class=\"quform-input quform-input-radio quform-input-25_33 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_25_33_d564b3_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_33\" id=\"quform_25_33_d564b3_6\" class=\"quform-field quform-field-radio quform-field-25_33 quform-field-25_33_6\" value=\"Very Satisfied\" \/><label for=\"quform_25_33_d564b3_6\" class=\"quform-option-label quform-option-label-25_33_6\"><span class=\"quform-option-text\">Very Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_33\" id=\"quform_25_33_d564b3_7\" class=\"quform-field quform-field-radio quform-field-25_33 quform-field-25_33_7\" value=\"Satisfied\" \/><label for=\"quform_25_33_d564b3_7\" class=\"quform-option-label quform-option-label-25_33_7\"><span class=\"quform-option-text\">Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_33\" id=\"quform_25_33_d564b3_8\" class=\"quform-field quform-field-radio quform-field-25_33 quform-field-25_33_8\" value=\"Neutral\" \/><label for=\"quform_25_33_d564b3_8\" class=\"quform-option-label quform-option-label-25_33_8\"><span class=\"quform-option-text\">Neutral<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_33\" id=\"quform_25_33_d564b3_9\" class=\"quform-field quform-field-radio quform-field-25_33 quform-field-25_33_9\" value=\"Dissatisfied\" \/><label for=\"quform_25_33_d564b3_9\" class=\"quform-option-label quform-option-label-25_33_9\"><span class=\"quform-option-text\">Dissatisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_33\" id=\"quform_25_33_d564b3_10\" class=\"quform-field quform-field-radio quform-field-25_33 quform-field-25_33_10\" value=\"Very Dissatisfied\" \/><label for=\"quform_25_33_d564b3_10\" class=\"quform-option-label quform-option-label-25_33_10\"><span class=\"quform-option-text\">Very Dissatisfied<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-25_34 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_35\"><div class=\"quform-element quform-element-radio quform-element-25_36 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_36\"><label class=\"quform-label-text\" id=\"quform_25_36_d564b3_label\">The Timeliness and speed of the service process you experienced.<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-25_36\"><div class=\"quform-input quform-input-radio quform-input-25_36 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_25_36_d564b3_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_36\" id=\"quform_25_36_d564b3_6\" class=\"quform-field quform-field-radio quform-field-25_36 quform-field-25_36_6\" value=\"Very Satisfied\" \/><label for=\"quform_25_36_d564b3_6\" class=\"quform-option-label quform-option-label-25_36_6\"><span class=\"quform-option-text\">Very Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_36\" id=\"quform_25_36_d564b3_7\" class=\"quform-field quform-field-radio quform-field-25_36 quform-field-25_36_7\" value=\"Satisfied\" \/><label for=\"quform_25_36_d564b3_7\" class=\"quform-option-label quform-option-label-25_36_7\"><span class=\"quform-option-text\">Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_36\" id=\"quform_25_36_d564b3_8\" class=\"quform-field quform-field-radio quform-field-25_36 quform-field-25_36_8\" value=\"Neutral\" \/><label for=\"quform_25_36_d564b3_8\" class=\"quform-option-label quform-option-label-25_36_8\"><span class=\"quform-option-text\">Neutral<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_36\" id=\"quform_25_36_d564b3_9\" class=\"quform-field quform-field-radio quform-field-25_36 quform-field-25_36_9\" value=\"Dissatisfied\" \/><label for=\"quform_25_36_d564b3_9\" class=\"quform-option-label quform-option-label-25_36_9\"><span class=\"quform-option-text\">Dissatisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_36\" id=\"quform_25_36_d564b3_10\" class=\"quform-field quform-field-radio quform-field-25_36 quform-field-25_36_10\" value=\"Very Dissatisfied\" \/><label for=\"quform_25_36_d564b3_10\" class=\"quform-option-label quform-option-label-25_36_10\"><span class=\"quform-option-text\">Very Dissatisfied<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-25_37 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_38\"><div class=\"quform-element quform-element-html quform-element-25_46 quform-cf\"><div class=\"quform-spacer\"><strong style=\"font-weight: 550;\">Your experience with the services provided by our medical staff.<\/strong><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-25_39 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_39\"><label class=\"quform-label-text\" id=\"quform_25_39_d564b3_label\">Doctor<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-25_39\"><div class=\"quform-input quform-input-radio quform-input-25_39 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_25_39_d564b3_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_39\" id=\"quform_25_39_d564b3_6\" class=\"quform-field quform-field-radio quform-field-25_39 quform-field-25_39_6\" value=\"Very Satisfied\" \/><label for=\"quform_25_39_d564b3_6\" class=\"quform-option-label quform-option-label-25_39_6\"><span class=\"quform-option-text\">Very Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_39\" id=\"quform_25_39_d564b3_7\" class=\"quform-field quform-field-radio quform-field-25_39 quform-field-25_39_7\" value=\"Satisfied\" \/><label for=\"quform_25_39_d564b3_7\" class=\"quform-option-label quform-option-label-25_39_7\"><span class=\"quform-option-text\">Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_39\" id=\"quform_25_39_d564b3_8\" class=\"quform-field quform-field-radio quform-field-25_39 quform-field-25_39_8\" value=\"Neutral\" \/><label for=\"quform_25_39_d564b3_8\" class=\"quform-option-label quform-option-label-25_39_8\"><span class=\"quform-option-text\">Neutral<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_39\" id=\"quform_25_39_d564b3_9\" class=\"quform-field quform-field-radio quform-field-25_39 quform-field-25_39_9\" value=\"Dissatisfied\" \/><label for=\"quform_25_39_d564b3_9\" class=\"quform-option-label quform-option-label-25_39_9\"><span class=\"quform-option-text\">Dissatisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_39\" id=\"quform_25_39_d564b3_10\" class=\"quform-field quform-field-radio quform-field-25_39 quform-field-25_39_10\" value=\"Very Dissatisfied\" \/><label for=\"quform_25_39_d564b3_10\" class=\"quform-option-label quform-option-label-25_39_10\"><span class=\"quform-option-text\">Very Dissatisfied<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-25_50 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_50\"><label class=\"quform-label-text\" id=\"quform_25_50_d564b3_label\">Nurse<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-25_50\"><div class=\"quform-input quform-input-radio quform-input-25_50 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_25_50_d564b3_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_50\" id=\"quform_25_50_d564b3_6\" class=\"quform-field quform-field-radio quform-field-25_50 quform-field-25_50_6\" value=\"Very Satisfied\" \/><label for=\"quform_25_50_d564b3_6\" class=\"quform-option-label quform-option-label-25_50_6\"><span class=\"quform-option-text\">Very Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_50\" id=\"quform_25_50_d564b3_7\" class=\"quform-field quform-field-radio quform-field-25_50 quform-field-25_50_7\" value=\"Satisfied\" \/><label for=\"quform_25_50_d564b3_7\" class=\"quform-option-label quform-option-label-25_50_7\"><span class=\"quform-option-text\">Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_50\" id=\"quform_25_50_d564b3_8\" class=\"quform-field quform-field-radio quform-field-25_50 quform-field-25_50_8\" value=\"Neutral\" \/><label for=\"quform_25_50_d564b3_8\" class=\"quform-option-label quform-option-label-25_50_8\"><span class=\"quform-option-text\">Neutral<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_50\" id=\"quform_25_50_d564b3_9\" class=\"quform-field quform-field-radio quform-field-25_50 quform-field-25_50_9\" value=\"Dissatisfied\" \/><label for=\"quform_25_50_d564b3_9\" class=\"quform-option-label quform-option-label-25_50_9\"><span class=\"quform-option-text\">Dissatisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_50\" id=\"quform_25_50_d564b3_10\" class=\"quform-field quform-field-radio quform-field-25_50 quform-field-25_50_10\" value=\"Very Dissatisfied\" \/><label for=\"quform_25_50_d564b3_10\" class=\"quform-option-label quform-option-label-25_50_10\"><span class=\"quform-option-text\">Very Dissatisfied<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-25_68 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_69\"><div class=\"quform-element quform-element-radio quform-element-25_70 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_70\"><label class=\"quform-label-text\" id=\"quform_25_70_d564b3_label\">The friendliness and helpfulness of our officers and staff in serving you.<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-25_70\"><div class=\"quform-input quform-input-radio quform-input-25_70 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_25_70_d564b3_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_70\" id=\"quform_25_70_d564b3_6\" class=\"quform-field quform-field-radio quform-field-25_70 quform-field-25_70_6\" value=\"Very Satisfied\" \/><label for=\"quform_25_70_d564b3_6\" class=\"quform-option-label quform-option-label-25_70_6\"><span class=\"quform-option-text\">Very Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_70\" id=\"quform_25_70_d564b3_7\" class=\"quform-field quform-field-radio quform-field-25_70 quform-field-25_70_7\" value=\"Satisfied\" \/><label for=\"quform_25_70_d564b3_7\" class=\"quform-option-label quform-option-label-25_70_7\"><span class=\"quform-option-text\">Satisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_70\" id=\"quform_25_70_d564b3_8\" class=\"quform-field quform-field-radio quform-field-25_70 quform-field-25_70_8\" value=\"Neutral\" \/><label for=\"quform_25_70_d564b3_8\" class=\"quform-option-label quform-option-label-25_70_8\"><span class=\"quform-option-text\">Neutral<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_70\" id=\"quform_25_70_d564b3_9\" class=\"quform-field quform-field-radio quform-field-25_70 quform-field-25_70_9\" value=\"Dissatisfied\" \/><label for=\"quform_25_70_d564b3_9\" class=\"quform-option-label quform-option-label-25_70_9\"><span class=\"quform-option-text\">Dissatisfied<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_70\" id=\"quform_25_70_d564b3_10\" class=\"quform-field quform-field-radio quform-field-25_70 quform-field-25_70_10\" value=\"Very Dissatisfied\" \/><label for=\"quform_25_70_d564b3_10\" class=\"quform-option-label quform-option-label-25_70_10\"><span class=\"quform-option-text\">Very Dissatisfied<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-25_56 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_57\"><div class=\"quform-element quform-element-html quform-element-25_58 quform-cf\"><div class=\"quform-spacer\"><strong style=\"color: green;\">Additional<\/strong><\/div><\/div><div class=\"quform-element quform-element-radio quform-element-25_59 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_59\"><label class=\"quform-label-text\" id=\"quform_25_59_d564b3_label\">Would you recommend our hospital to your associates or colleagues?<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-radio quform-inner-25_59\"><div class=\"quform-input quform-input-radio quform-input-25_59 quform-cf\"><div class=\"quform-options quform-cf quform-options-inline quform-options-simple\" role=\"radiogroup\" aria-labelledby=\"quform_25_59_d564b3_label\"><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_59\" id=\"quform_25_59_d564b3_1\" class=\"quform-field quform-field-radio quform-field-25_59 quform-field-25_59_1\" value=\"Yes\" \/><label for=\"quform_25_59_d564b3_1\" class=\"quform-option-label quform-option-label-25_59_1\"><span class=\"quform-option-text\">Yes<\/span><\/label><\/div><div class=\"quform-option\"><input type=\"radio\" name=\"quform_25_59\" id=\"quform_25_59_d564b3_2\" class=\"quform-field quform-field-radio quform-field-25_59 quform-field-25_59_2\" value=\"No\" \/><label for=\"quform_25_59_d564b3_2\" class=\"quform-option-label quform-option-label-25_59_2\"><span class=\"quform-option-text\">No<\/span><\/label><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-25_61 quform-1-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_62\"><div class=\"quform-element quform-element-html quform-element-25_63 quform-cf\"><div class=\"quform-spacer\"><strong>Your feedback and appreciation are highly valuable to us. You may share them in this section.<\/strong><\/div><\/div><div class=\"quform-element quform-element-text quform-element-25_65 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-inner quform-inner-text quform-inner-25_65\"><div class=\"quform-input quform-input-text quform-input-25_65 quform-cf\"><input type=\"text\" id=\"quform_25_65_d564b3\" name=\"quform_25_65\" class=\"quform-field quform-field-text quform-field-25_65\" placeholder=\"Enter your feedback\" \/><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-row quform-element-row-25_7 quform-5-columns quform-element-row-size-fixed quform-responsive-columns-phone-landscape\"><div class=\"quform-element quform-element-column quform-element-25_8\"><div class=\"quform-element quform-element-text quform-element-25_12 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_12\"><label class=\"quform-label-text\" for=\"quform_25_12_d564b3\">Name<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-25_12\"><div class=\"quform-input quform-input-text quform-input-25_12 quform-cf\"><input type=\"text\" id=\"quform_25_12_d564b3\" name=\"quform_25_12\" class=\"quform-field quform-field-text quform-field-25_12\" placeholder=\"Enter your name\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-25_18\"><div class=\"quform-element quform-element-text quform-element-25_20 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_20\"><label class=\"quform-label-text\" for=\"quform_25_20_d564b3\">Phone No<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-25_20\"><div class=\"quform-input quform-input-text quform-input-25_20 quform-cf\"><input type=\"text\" id=\"quform_25_20_d564b3\" name=\"quform_25_20\" class=\"quform-field quform-field-text quform-field-25_20\" placeholder=\"Enter your phone number\" maxlength=\"12\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-25_9\"><div class=\"quform-element quform-element-text quform-element-25_67 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_67\"><label class=\"quform-label-text\" for=\"quform_25_67_d564b3\">Date of birth<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-25_67\"><div class=\"quform-input quform-input-text quform-input-25_67 quform-cf\"><input type=\"text\" id=\"quform_25_67_d564b3\" name=\"quform_25_67\" class=\"quform-field quform-field-text quform-field-25_67\" placeholder=\"example : 12-07-1987\" maxlength=\"10\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-25_10\"><div class=\"quform-element quform-element-text quform-element-25_14 quform-cf quform-element-optional\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_14\"><label class=\"quform-label-text\" for=\"quform_25_14_d564b3\">Medical Record No  <b>(Optional)<\/b><\/label><\/div><div class=\"quform-inner quform-inner-text quform-inner-25_14\"><div class=\"quform-input quform-input-text quform-input-25_14 quform-cf\"><input type=\"text\" id=\"quform_25_14_d564b3\" name=\"quform_25_14\" class=\"quform-field quform-field-text quform-field-25_14\" placeholder=\"Enter your medical record - optional\" maxlength=\"8\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-column quform-element-25_11\"><div class=\"quform-element quform-element-select quform-element-25_16 quform-cf quform-element-required\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_16\"><label class=\"quform-label-text\" for=\"quform_25_16_d564b3\">Polyclinic \/ Services<span class=\"quform-required\">*<\/span><\/label><div class=\"quform-tooltip-icon quform-tooltip-icon-hover\"><i class=\"qicon-question-circle\"><\/i><div class=\"quform-tooltip-icon-content\">Silahkan Pilih<\/div><\/div><\/div><div class=\"quform-inner quform-inner-select quform-inner-25_16\"><div class=\"quform-input quform-input-select quform-input-25_16 quform-cf\"><select id=\"quform_25_16_d564b3\" name=\"quform_25_16\" class=\"quform-field quform-field-select quform-field-25_16\"><option value=\"\" selected=\"selected\">Choose Services<\/option><option value=\"Acupuncture Clinic\">Acupuncture Clinic<\/option><option value=\"Pediatric Clinic\">Pediatric Clinic<\/option><option value=\"Anesthesia Clinic\">Anesthesia Clinic<\/option><option value=\"Pediatric Surgery Clinic\">Pediatric Surgery Clinic<\/option><option value=\"Digestive Surgery Clinic\">Digestive Surgery Clinic<\/option><option value=\"Oral Surgery Clinic\">Oral Surgery Clinic<\/option><option value=\"Surgical Oncology Clinic\">Surgical Oncology Clinic<\/option><option value=\"Orthopedic Surgery Clinic\">Orthopedic Surgery Clinic<\/option><option value=\"Plastic Surgery Clinic\">Plastic Surgery Clinic<\/option><option value=\"Neurosurgery Clinic\">Neurosurgery Clinic<\/option><option value=\"General Surgery Clinic\">General Surgery Clinic<\/option><option value=\"Dermatology Clinic\">Dermatology Clinic<\/option><option value=\"Dental Clinic\">Dental Clinic<\/option><option value=\"Nutrition Clinic\">Nutrition Clinic<\/option><option value=\"Cardiology Clinic\">Cardiology Clinic<\/option><option value=\"Psychiatry Clinic\">Psychiatry Clinic<\/option><option value=\"Obstetrics and Gynecology Clinic\">Obstetrics and Gynecology Clinic<\/option><option value=\"Eye Clinic\">Eye Clinic<\/option><option value=\"Pulmonology Clinic\">Pulmonology Clinic<\/option><option value=\"Internal Medicine Clinic\">Internal Medicine Clinic<\/option><option value=\"Psychology Clinic\">Psychology Clinic<\/option><option value=\"Neurology Clinic\">Neurology Clinic<\/option><option value=\"TB DOTS Clinic\">TB DOTS Clinic<\/option><option value=\"Telemedicine Clinic\">Telemedicine Clinic<\/option><option value=\"ENT Clinic\">ENT Clinic<\/option><option value=\"Urology Clinic\">Urology Clinic<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"quform-element quform-element-textarea quform-element-25_363601 quform-sr-only quform-cf\" style=\"clip: rect(1px, 1px, 1px, 1px); clip-path: inset(50%); position: absolute !important; height: 1px; width: 1px; overflow: hidden;\"><div class=\"quform-spacer\"><div class=\"quform-label quform-label-25_363601\"><label class=\"quform-label-text\" for=\"quform_25_363601_d564b3\">Contact Email<span class=\"quform-required\">*<\/span><\/label><\/div><div class=\"quform-inner quform-inner-25_363601\"><textarea id=\"quform_25_363601_d564b3\" name=\"quform_25_363601\" class=\"quform-field quform-field-textarea quform-field-25_363601\" tabindex=\"-1\" autocomplete=\"new-password\"><\/textarea><\/div><\/div><\/div><div class=\"quform-element quform-element-submit quform-element-25_2 quform-cf quform-button-style-theme\"><div class=\"quform-button-submit quform-button-submit-default quform-button-submit-25_2\"><button name=\"quform_submit\" type=\"submit\" class=\"quform-submit\" value=\"submit\"><span class=\"quform-button-text quform-button-submit-text\">Save<\/span><\/button><\/div><div class=\"quform-loading quform-loading-position-left quform-loading-type-spinner-1\"><div class=\"quform-loading-inner\"><div class=\"quform-loading-spinner\"><div class=\"quform-loading-spinner-inner\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/div><\/form><\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Choose Language : Outpatient Questionnaire<\/p>\n","protected":false},"author":20,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_monsterinsights_skip_tracking":false,"footnotes":""},"class_list":["post-24060","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.2 - 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