Move to the text

Questionnaire

Request of the questionnaire cooperation

Thank you for visiting our homepage.
To a questionnaire following for in future more service improvement hope that have cooperate.

On having you answer a questionnaire

■You read "a privacy policy" on answering for a questionnaire, and please fill it in after an agreement.
■Please input a phone number (home or cell-phone) to get of the communication into a phone number column by all means.
■As an answer may take time, please refer for the dispatch over a telephone.
■Please check reception setting (unwanted e-mail setting) to be able to receive a reply email.
■Very sorry for your inconvenience, but please contact me from this again by any chance when there is not a reply.

Questionnaire form

▼Information of respondent
Tell it about a visitor if all right.
Sex
Age
Area to live
▼Impression when it was done the next House
How was the atmosphere of our House?
The correspondence of the reception desk?
How long did it take for waiting?
About correspondence of the nursing staff
About the medical examination of the doctor
▼About facilities facilities
General impression
In-hospital guidance indication
▼About our site
Easiness in seeing of the whole site ※required
The main reading purpose? ※required
↑One of answering it others
The information to want you to enrich? ※required
Multiple answers allowed
↑One of answering it others
If there is an opinion request, write it freely
Thank you for cooperation.
With the above you push the button to "a confirmation screen", and please confirm input contents if all right.
0
0
5
8
1
1
Medical corporation Fukuji fortune surgery hospital
〒641-0021
Wakaurahigashi, Wakayama-shi, Wakayama
3-5-31
TEL. 073-445-3101
FAX. 073-445-4660
Back to TOP