Patient Satisfaction Survey

Thank you for choosing [Clinic/Hospital Name]. Your health and well-being are our top priorities. Please take a few moments to complete this confidential survey about your recent visit on [Date]. Your feedback helps us improve our services and provide the highest quality care.

1. Demographics & Visit Information (Optional)

To help us categorize your feedback, please provide a few details.

Name of Provider/Doctor seen:

2. Access and Scheduling

Please rate your experience upon entering the facility.

	Question	Excellent	Good	Fair	Poor	N/A
	A	B	C	D	E	F
1	Ease of scheduling your appointment
2	Convenience of available appointment times
3	Efficiency of the automated or online booking system
4	Speed of phone response when calling our office
5	Ability to get a timely appointment for an urgent matter

3. Arrival and Reception (Front Desk)

Please rate your experience upon entering the facility.

	Question	Excellent	Good	Fair	Poor	N/A
	A	B	C	D	E	F
1	Friendliness and courtesy of the reception staff
2	Helpfulness of the check-in process
3	Respect for your privacy during check-in
4	Clear communication regarding wait times

How long did you wait in the reception area past your scheduled time?

< 10 mins

10–20 mins

20–40 mins

40+ mins

4. Facility Environment

Please rate the physical environment of our clinic/hospital.

	Question	Excellent	Good	Fair	Poor	N/A
	A	B	C	D	E	F
1	Cleanliness of the waiting room and exam rooms
2	Comfort of the seating and temperature
3	Clarity of signage and ease of navigating the building
4	Accessibility and cleanliness of the restrooms

5. Medical and Nursing Staff

Please rate your interactions with nurses, medical assistants, and technicians.

	Question	Excellent	Good	Fair	Poor	N/A
	A	B	C	D	E	F
1	Courtesy, friendliness, and respect shown by the staff
2	Skill and care shown during intake (e.g., vitals, blood draw)
3	Ability of the staff to answer your initial questions

6. Your Healthcare Provider (Doctor, NP, PA)

Please rate the specific provider you saw during your visit.

	Question	Excellent	Good	Fair	Poor	N/A
	A	B	C	D	E	F
1	The provider listened to your concerns carefully
2	Explanations about your condition/treatment were easy to understand
3	Amount of time the provider spent with you
4	Thoroughness of the examination and care provided
5	Inclusion of your input in decisions about your healthcare
6	Concern shown for your comfort and emotional well-being

7. Billing, Insurance, and Follow-Up

Please rate the administrative and financial aspects of your care.

	Question	Excellent	Good	Fair	Poor	N/A
	A	B	C	D	E	F
1	Clear explanations of costs, co-pays, or financial responsibilities
2	Ease of the check-out and payment process
3	Clear instructions given regarding prescriptions or follow-up care
4	Convenience of getting your test results (via portal, phone, etc.)

8. Telehealth / Virtual Visits (If Applicable)

Skip this section if your visit was in-person.

	Question	Excellent	Good	Fair	Poor	N/A
	A	B	C	D	E	F
1	Ease of connecting to the video/audio platform
2	Quality of the video and audio connection
3	Privacy and security felt during the virtual consultation

9. Overall Experience & Loyalty

How likely are you to recommend our practice or hospital to family and friends? (1 = Not At All Likely, 5 = Neutral, 10 = Extremely Likely)

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10. Open-Ended Feedback

What did we do exceptionally well during your visit? Is there a specific staff member you would like to recognize?

What areas do you feel we could improve upon to better serve our patients?

Contact Information (Optional)

If you would like a manager to contact you regarding a specific concern or issue raised in this survey, please provide your contact info below:

Name

Phone Number

Email Address