Net Promoter Score (NPS) Survey
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Net Promoter Score (NPS) Survey

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Net Promoter Score (NPS) Survey

Net Promoter Score (NPS) Survey

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Likelihood to Recommend (0-10)
Option A
Option B
Option C
Primary Reason for Score
How Long a Patient
Select an option...
What We Do Well
Enter details here...
What We Could Improve
Enter details here...
Contact Permission
Option A
Option B
Option C
Survey Date
03/15/1985
Provider Seen
Dr. Sarah Chen
Additional Comments
Enter details here...
Submit
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The Net Promoter Score (NPS) Survey provides a fast, industry-standard method for measuring patient loyalty and likelihood to recommend your practice to others. Built around the classic NPS question on a 0-to-10 scale, this template automatically segments respondents into Promoters (9-10), Passives (7-8), and Detractors (0-6), giving you a single powerful metric that correlates with patient retention and organic growth. The brevity of this survey maximizes response rates while still capturing the most actionable loyalty data available.

Beyond the core NPS question, this survey includes a follow-up asking the patient to select the primary reasons behind their score from a curated list of common satisfaction drivers and detractors. Options include provider quality, staff friendliness, wait times, facility environment, billing experience, and care outcomes. An open-ended comment field invites the patient to elaborate in their own words, providing the qualitative context that transforms a number into an actionable insight. A final question captures how long the patient has been with the practice, enabling you to segment NPS by patient tenure.

This template is ideal for any healthcare organization that wants a lightweight, repeatable satisfaction metric that can be tracked monthly or quarterly. Practices use NPS to set organizational goals, compare performance across locations or departments, identify at-risk patients before they leave, and celebrate wins when scores improve. The simplicity of the survey makes it easy to integrate into automated post-visit workflows, ensuring consistent data collection without survey fatigue.

What's included

  • Standard 0-10 Net Promoter Score recommendation question
  • Automatic Promoter, Passive, and Detractor segmentation
  • Satisfaction driver and detractor reason selection
  • Open-ended fields for qualitative praise and improvement suggestions
  • Patient tenure capture for loyalty trend analysis
  • Contact permission for follow-up on detractor feedback

Who uses this template

  • Healthcare organizations tracking a single loyalty metric over time
  • Multi-location practices comparing NPS across sites and departments
  • Marketing teams identifying promoters for testimonials and referrals
  • Operations leaders detecting detractor trends before patient churn

All form fields

9 fields across 1 page. Customize any field after signing up.

Likelihood to Recommend (0-10)Multiple Choice
Primary Reason for ScoreCheckbox
How Long a PatientDropdown
What We Do WellLong Text
What We Could ImproveLong Text
Contact PermissionMultiple Choice
Survey DateDate
Provider SeenText
Additional CommentsLong Text
8 min saved per patient98% patient satisfaction3x faster than paper

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Net Promoter Score (NPS) SurveyUse this template