feedback.nakaserohospital.com Open in urlscan Pro
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1 forms found in the DOM

POST insert.php

<form id="contact" action="insert.php" method="post" onsubmit="this.submit(); this.reset();>
      <table>
        <tr>
          <td><img src=" nhl.png"="" alt="logo" width="100" height="90">
  <h3>FEEDBACK FORM</h3>
  <div align="centre">
    <h4> CUSTOMER CARE HELPLINE:<img src="png.png" alt="logo" width="15" height="15">
      <img src="phone.png" alt="logo" width="15" height="15"> 0776 970 220
    </h4>
  </div>
  <table>
    <tbody>
      <tr>
        <td>
          <fieldset>
            <label for="name"><strong>Name</strong></label>
            <input placeholder="Your Name (optional)" name="name" type="textbox" tabindex="2">
          </fieldset>
        </td>
        <td></td>
        <td></td>
        <td></td>
        <td>
          <fieldset>
            <label for="date"><strong>Date</strong></label>
            <input name="date" type="date" tabindex="1" autofocus="">
          </fieldset>
        </td>
      </tr>
    </tbody>
  </table>
  <h4>
    <div align="center" ;="">
      <p><strong>How do you feel about the service you recieved?</strong> </p>
    </div>
  </h4>
  <hr>
  <fieldset id="waiting">
    <label for="date"><strong>Waiting Time</strong> </label>
    <p>
    </p>
    <table border="0">
      <tbody>
        <tr>
          <td>
            <h4><label><input type="radio" value="Acceptable" name="waiting">Acceptable</label></h4>
          </td>
          <td></td>
          <td></td>
          <td>
            <h4><label><input type="radio" value="Unacceptable" name="waiting">Unacceptable</label></h4>
          </td>
        </tr>
      </tbody>
    </table>
    <p></p>
  </fieldset>
  <fieldset id="group2">
    <label for="quality"><strong>Quality Of Customer Care</strong></label>
    <p>
    </p>
    <table cellspacing="8" cellpading="0">
      <tbody>
        <tr>
          <td>
            <h4><label><input type="radio" value="Very Good" name="quality">Very Good</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="Good" name="quality">Good</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="Poor" name="quality">Poor</label></h4>
          </td>
        </tr>
      </tbody>
    </table>
    <p></p>
  </fieldset>
  <fieldset id="environment">
    <label for="date"><strong>Environment/Atmosphere</strong></label>
    <p>
    </p>
    <table cellspacing="8" cellpading="0">
      <tbody>
        <tr>
          <td>
            <h4><label><input type="radio" value="Very Good" name="Environment">Very Good</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="Good" name="Environment">Good</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="Poor" name="Environment">Poor</label></h4>
          </td>
        </tr>
      </tbody>
    </table>
    <p></p>
  </fieldset>
  <fieldset id="experience">
    <label for="experience"><strong>Overall Experience</strong> </label>
    <p>
    </p>
    <table cellspacing="8" cellpading="0">
      <tbody>
        <tr>
          <td>
            <h4><label><input type="radio" value="Very Good" name="experience">Very Good</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="Good" name="experience">Good</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="Poor" name="experience">Poor</label></h4>
          </td>
        </tr>
      </tbody>
    </table>
    <p></p>
  </fieldset>
  <fieldset id="scale">
    <h6><label for="scale"><strong>On a scale of 1-10, how likely are you to recommend the hospital?</strong></label></h6>
    <p>
    </p>
    <table cellspacing="8" cellpading="0">
      <tbody>
        <tr>
          <td>
            <h4><label><input type="radio" value="1" name="scale">1</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="2" name="scale">2</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="3" name="scale">3</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="4" name="scale">4</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="5" name="scale">5</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="6" name="scale">6</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="7" name="scale">7</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="8" name="scale">8</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="9" name="scale">9</label></h4>
          </td>
          <td>
            <h4><label><input type="radio" value="10" name="scale">10</label></h4>
          </td>
        </tr>
      </tbody>
    </table>
    <p></p>
  </fieldset>
  <fieldset>
    <h6><label for="scale"><strong>Please let us know how we can improve</strong></label></h6>
    <textarea rows="6" cols="100" name="improve"></textarea>
  </fieldset>
  <fieldset>
    <button type="submit" name="submit" id="contact-submit" data-submit="...Sending">Submit Now</button>
  </fieldset>
</form>

Text Content

FEEDBACK FORM

CUSTOMER CARE HELPLINE: 0776 970 220

Name Date

HOW DO YOU FEEL ABOUT THE SERVICE YOU RECIEVED?

--------------------------------------------------------------------------------

Waiting Time



ACCEPTABLE

UNACCEPTABLE



Quality Of Customer Care



VERY GOOD

GOOD

POOR



Environment/Atmosphere



VERY GOOD

GOOD

POOR



Overall Experience



VERY GOOD

GOOD

POOR



ON A SCALE OF 1-10, HOW LIKELY ARE YOU TO RECOMMEND THE HOSPITAL?



1

2

3

4

5

6

7

8

9

10



PLEASE LET US KNOW HOW WE CAN IMPROVE

Submit Now