Patient Satisfaction Survey

A comprehensive Patient Satisfaction Survey for measuring the patient experience across appointment scheduling, waiting times, clinic facilities, staff interactions, provider communication, treatment involvement, overall satisfaction, and likelihood to recommend the clinic, with options for anonymous feedback and follow-up.

Healthcare & Clinical

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Related topics

  • Anonymous Feedback
  • Appointment Scheduling
  • Clinic Cleanliness
  • Clinic Feedback
  • Customer Satisfaction
  • Front Desk Service
  • Healthcare
  • Healthcare Survey
  • Net Promoter Score
  • NPS
  • Open Feedback
  • Overall Satisfaction
  • Patient Engagement
  • Patient Experience
  • Patient Feedback
  • Patient Loyalty
  • Patient Satisfaction Survey
  • Provider Care
  • Provider Communication
  • Service Quality
  • Staff Feedback
  • Treatment Experience
  • Visit Experience
  • Waiting Time

Patient Satisfaction Survey

Administrative Details

Date of Visit
Select Date
Provider Seen
Dr. Jane Smith
Therapist Alan Poe

Scheduling & Waiting Times

Ease of Scheduling

How easy was it to book your appointment?

☆☆☆☆☆
Waiting Room Time

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

Less than 10 minutes
10–20 minutes
20–30 minutes
More than 30 minutes

Facility & Staff Interactions

Score your experience

Choose a rating from 1 (Very Poor) to 10 (Excellent).

12345678910
Clinic Cleanliness

Choose a rating from 1 (Very Poor) to 10 (Excellent).

12345678910

Provider Care & Communication

Listening Skills

Did the provider listen carefully to your concerns?

☆☆☆☆☆
Clear Explanations

Did the provider explain things in a way that was easy to understand?

☆☆☆☆☆
Time Spent

Did you feel the provider spent enough time with you, or did you feel rushed?

☆☆☆☆☆
Involvement in Decisions

Were you given a say in your treatment plan options?

☆☆☆☆☆

Overall Experience & Loyalty

Overall Satisfaction

Rate your overall visit experience from 1 (Very Poor) to 10 (Excellent).

12345678910
Net Promoter Score (NPS)

How likely are you to recommend our clinic to family and friends? 0 (Not at all likely) to 10 (Extremely likely).

12345678910
Open Feedback
Type your detailed response here...

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