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.
To help us categorize your feedback, please provide a few details.
Age Group:
Under 18
18–34
35–54
55–64
65+
Type of Visit:
Routine/Preventative Care
Urgent Care / Illness
Specialist Consultation
Inpatient Stay / Surgery
Telehealth (Virtual)
Name of Provider/Doctor seen:
Please rate your experience upon entering the facility.
Question | Excellent | Good | Fair | Poor | N/A | |
|---|---|---|---|---|---|---|
Ease of scheduling your appointment | ||||||
Convenience of available appointment times | ||||||
Efficiency of the automated or online booking system | ||||||
Speed of phone response when calling our office | ||||||
Ability to get a timely appointment for an urgent matter |
Please rate your experience upon entering the facility.
Question | Excellent | Good | Fair | Poor | N/A | |
|---|---|---|---|---|---|---|
Friendliness and courtesy of the reception staff | ||||||
Helpfulness of the check-in process | ||||||
Respect for your privacy during check-in | ||||||
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
Please rate the physical environment of our clinic/hospital.
Question | Excellent | Good | Fair | Poor | N/A | |
|---|---|---|---|---|---|---|
Cleanliness of the waiting room and exam rooms | ||||||
Comfort of the seating and temperature | ||||||
Clarity of signage and ease of navigating the building | ||||||
Accessibility and cleanliness of the restrooms |
Please rate your interactions with nurses, medical assistants, and technicians.
Question | Excellent | Good | Fair | Poor | N/A | |
|---|---|---|---|---|---|---|
Courtesy, friendliness, and respect shown by the staff | ||||||
Skill and care shown during intake (e.g., vitals, blood draw) | ||||||
Ability of the staff to answer your initial questions |
Please rate the specific provider you saw during your visit.
Question | Excellent | Good | Fair | Poor | N/A | |
|---|---|---|---|---|---|---|
The provider listened to your concerns carefully | ||||||
Explanations about your condition/treatment were easy to understand | ||||||
Amount of time the provider spent with you | ||||||
Thoroughness of the examination and care provided | ||||||
Inclusion of your input in decisions about your healthcare | ||||||
Concern shown for your comfort and emotional well-being |
Please rate the administrative and financial aspects of your care.
Question | Excellent | Good | Fair | Poor | N/A | |
|---|---|---|---|---|---|---|
Clear explanations of costs, co-pays, or financial responsibilities | ||||||
Ease of the check-out and payment process | ||||||
Clear instructions given regarding prescriptions or follow-up care | ||||||
Convenience of getting your test results (via portal, phone, etc.) |
Skip this section if your visit was in-person.
Question | Excellent | Good | Fair | Poor | N/A | |
|---|---|---|---|---|---|---|
Ease of connecting to the video/audio platform | ||||||
Quality of the video and audio connection | ||||||
Privacy and security felt during the virtual consultation |
How likely are you to recommend our practice or hospital to family and friends? (1 = Not At All Likely, 5 = Neutral, 10 = Extremely Likely)
Overall, how would you rate the quality of care you received?
Excellent
Very Good
Good
Fair
Poor
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?
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