Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Appointment Feedback Survey
Scheduling Ease
- Very easy
- Easy
- Neither easy nor difficult
- Difficult
- Very difficult
- Not applicable
Appointment Availability
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Pre-Visit Communication
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Check-In Experience
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Wait Time Rating
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Waiting Room Comfort
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Staff Communication About Delays
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Check-Out Process
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Overall Appointment Rating
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Suggestions for Improvement
Appointment Feedback Survey template from formisoft.com. formisoft.com/intake-templates/appointment-feedback