Consent Form for Participation in a Research Study

You are invited to participate in a research case study conducted by Dr. Ishrat Nazir. The purpose of this
case study is to know impact of hospital services on outpatient satisfaction in Murshid hospital Karachi.

Your participation will involve responding to the given questions. There are no known risks associated
with this research. There are no known benefits to you that would result from your participation in this
research.

Participant’s signature___________________________Date:___________________

DEMOGRAPHIC FORM

Name: __________________________ Age: ______________________________

Gender: ________________________ Educational status: ___________________________

Primary Language: _______________________

 PATIENT SATISFACTION SURVEY

Strongly Disagree
PLEASE CIRCLE THE ONE NUMBER FOR EACH

Strongly Agree
QUESTION THAT COMES CLOSEST TO REFLECTING
YOUR OPINIONABOUT IT.

Disagree
Neutral
Agree
Tangible Dimensions
1 1 2 3 4 5
Hospital has all required latest equipments.
2 1 2 3 4 5
Physical facilities are visually appealing.
3 1 2 3 4 5
Medical services in hospital are conveniently located.
Reliability Dimensions
4 1 2 3 4 5
Doctors and staff spend enough time with patient to evaluate
the diseases.
5 1 2 3 4 5
Doctors and staff take efforts to maintain accurate records.
6 1 2 3 4 5
Expectations are fully met with regards to treatment.
Responsiveness Dimensions
7 1 2 3 4 5
Caring and quick response of a paramedic staff to patient in
examination room.
8 1 2 3 4 5
Doctors carefully check everything when treating and
examining.
9 1 2 3 4 5
Staff of reception counter is cooperative and helpful.
Assurance Dimensions
10 1 2 3 4 5
Patient feels relaxed and assured while services are being
provided.
11 1 2 3 4 5
Doctor and staff treat in a very friendly and courteous manner.
12 1 2 3 4 5
Doctor spends plenty of time explaining the reason for medical
treatment.
Empathy Dimensions
13 1 2 3 4 5
Doctor and staff carefully listen and give attention to patient
problem.
14 1 2 3 4 5
Doctor and staff treat patient with care and respectful manner.
15 1 2 3 4 5
Doctor and staff show concern and respect to patient and
his/her family.
 Patient Satisfaction
16 1 2 3 4 5
Satisfied with medical service available to revisit again.
17 1 2 3 4 5
Overall hospital provides good quality service to its patients.
18 1 2 3 4 5
Medical services are recommended to family and friends for
referral