CRM Survey Step 1 of 3 33% Basic InformationName* Middle Name Last Name Are you a member of Expat Privilege Card?* Yes No Nationality*AfghanAlbanianAlgerianAndorranAngolanAntiguan or BarbudanArgentineArmenianAustralianAustrianAzerbaijani, AzeriBahamianBahrainiBengaliBarbadianBelarusianBelgianBelizeanBeninese, BeninoisBhutaneseBolivianBosnian or HerzegovinianMotswana, BotswananBrazilianBruneianBulgarianBurkinabéBurmeseBurundianCabo VerdeanCambodianCameroonianCanadianCentral AfricanChadianChileanChineseColombianComoran, ComorianCongoleseCongoleseCosta RicanIvorianCroatianCubanCypriotCzechDanishDjiboutianDominicanDominicanTimoreseEcuadorianEgyptianSalvadoranEquatorial Guinean, EquatoguineanEritreanEstonianEthiopianFijianFinnishFrenchGaboneseGambianGeorgianGermanGhanaianGibraltarGreek, HellenicGrenadianGuatemalanGuineanBissau-GuineanGuyaneseHaitianHonduranHungarian, MagyarIcelandicIndianIndonesianIranian, PersianIraqiIrishIsraeliItalianIvorianJamaicanJapaneseJordanianKazakhstani, KazakhKenyanI-KiribatiNorth KoreanSouth KoreanKuwaitiKyrgyzstani, Kyrgyz, Kirgiz, KirghizLao, LaotianLatvian, LettishLebaneseBasothoLiberianLibyanLiechtensteinerLithuanianLuxembourg, LuxembourgishMacedonianMalagasyMalawianMalaysianMaldivianMalian, MalineseMalteseMarshalleseMartiniquais, MartinicanMauritanianMauritianMexicanMicronesianMoldovanMonégasque, MonacanMongolianMontenegrinMoroccanMozambicanNamibianNauruanNepali, NepaleseDutch, NetherlandicNew Zealand, NZ, ZelanianNicaraguanNigerienNigerianNorthern MariananNorwegianOmaniPakistaniPalauanPalestinianPanamanianPapua New Guinean, PapuanParaguayanPeruvianFilipino, PhilippinePolishPortuguesePuerto RicanQatariRomanianRussianRwandanKittitian or NevisianSaint LucianSaint Vincentian, VincentianSamoanSammarineseSão ToméanSaudi, Saudi ArabianSenegaleseSerbianSeychelloisSierra LeoneanSingapore, SingaporeanSlovakSlovenian, SloveneSolomon IslandSomaliSouth AfricanSouth SudaneseSpanishSri LankanSudaneseSurinameseSwaziSwedishSwissSyrianTajikistaniTanzanianThaiTimoreseTogoleseTokelauanTonganTrinidadian or TobagonianTunisianTurkishTurkmenTuvaluanUgandanUkrainianEmirati, Emirian, EmiriUK, BritishUnited States, U.S., AmericanUruguayanUzbekistani, UzbekNi-Vanuatu, VanuatuanVaticanVenezuelanVietnameseYemeniZambianZimbabwean How satisfied are you with appointment arrangement?1. How satisfied are you with convenience to get appointment with your doctor(s) upon your request?* Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied 2. Have you or your family members ever missed an appointment with your doctors at Bangkok Hospital Phuket?*(If you or your family members never miss an appointment, please go to next page) Yes Never 3. What is the main reason that makes you or your family members miss an appointment with your doctors at Bangkok Hospital Phuket?(Choose only 1 answer) Found it is unnecessary to see the doctors again Found it is more convenient to buy over-the-counter medicine Want to receive medical services from other health care provider(s) Travel back to your home country Concern about the price/cost saving Inconvenient to travel to the hospital Your doctors' timetable does not suit your availability Wish to go to another healthcare service provider where your Thai Social Security Fund scheme applies Found the services at Bangkok Hospital Phuket to be unsatisfactory Never miss appointment 1. Are you a member of Expat Privilege Card ? Yes No 2. Do you have the complete and clear information about the benefits of Expat Privilege Card?* Yes No Never have any information about Expat Privilege Card 3. Have you ever used Expat Privilege Card at the hospital’s business friend places?* Yes No 4. Could you please mention the name of the hospital’s business friends that you have used their facilities?*5. How satisfied are you with the benefits from being a member of Expat Privilege Card?* Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied 6. Could you please advise any businesses or companies that you would like to get special offers from them as you are the member of Expat Privilege Card?*7. What would you expect to receive from being a member of Expat Privilege Card besides special discount from Bangkok Hospital Phuket?*Untitled* * Please check this box to confirm that you have read, understood and agree to the Terms and Conditions and Privacy Policy.
