Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Net Promoter Score (NPS) Survey
Likelihood to Recommend (0-10)
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
Primary Reason for Score
How Long a Patient
- First visit
- Less than 1 year
- 1–3 years
- More than 3 years
What We Do Well
What We Could Improve
Contact Permission
- Yes, you may contact me about my feedback
- No, please do not contact me
Survey Date
____ / ____ / ________
Provider Seen
Additional Comments
Net Promoter Score (NPS) Survey template from formisoft.com. formisoft.com/intake-templates/nps-survey