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Patient Satisfaction Survey

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Patient Satisfaction Survey

Page 1 of 2

Overall Care Rating
Option A
Option B
Option C
Provider Communication
Option A
Option B
Option C
Staff Friendliness
Option A
Option B
Option C
Wait Time Satisfaction
Very satisfied
Satisfied
Neutral
Dissatisfied
Facility Cleanliness
Option A
Option B
Option C
Ease of Scheduling
Option A
Option B
Option C
Treatment Explanation Clarity
Option A
Option B
Option C
Billing Transparency
Option A
Option B
Option C
Likelihood to Recommend
Option A
Option B
Option C
Areas for Improvement
Visit Date
03/15/1985
Additional Comments
Enter details here...
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The Patient Satisfaction Survey is a thorough instrument for measuring how patients perceive the quality of care they receive at your practice. Modeled after CAHPS (Consumer Assessment of Healthcare Providers and Systems) methodology, this template captures satisfaction across multiple dimensions including provider communication, staff friendliness, wait times, facility cleanliness, and overall care experience. Each question uses validated rating scales that produce actionable data for quality improvement initiatives.

This survey covers the full patient journey from scheduling the appointment through check-out, ensuring no touchpoint is overlooked. Patients rate their experience with front desk interactions, nurse and medical assistant professionalism, provider attentiveness and explanations, treatment plan clarity, and billing transparency. Open-ended comment fields allow patients to share specific praise or concerns that structured questions might miss, giving your team the qualitative insights needed to complement quantitative scores.

Designed for primary care offices, specialty clinics, urgent care centers, and multi-provider group practices, this survey can be sent automatically after each visit or on a periodic basis. The structured format makes it easy to track satisfaction trends over time, benchmark against industry standards, and identify areas where targeted training or process improvements will have the greatest impact on patient retention and referral rates.

What's included

  • Validated satisfaction rating scales across care dimensions
  • Provider communication and bedside manner assessment
  • Office environment and staff professionalism ratings
  • Wait time and scheduling convenience evaluation
  • Open-ended comment fields for qualitative feedback
  • Likelihood to recommend and return metrics

Who uses this template

  • Primary care and family medicine practices tracking patient experience
  • Specialty clinics benchmarking against CAHPS quality standards
  • Multi-provider groups comparing satisfaction across providers
  • Healthcare organizations preparing for accreditation reviews

All form fields

12 fields across 2 pages. Customize any field after signing up.

Overall Care RatingMultiple Choice
Provider CommunicationMultiple Choice
Staff FriendlinessMultiple Choice
Wait Time SatisfactionMultiple Choice
Facility CleanlinessMultiple Choice
Ease of SchedulingMultiple Choice
Treatment Explanation ClarityMultiple Choice
Billing TransparencyMultiple Choice
Likelihood to RecommendMultiple Choice
Areas for ImprovementCheckbox
Visit DateDate
Additional CommentsLong Text
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Patient Satisfaction SurveyUse this template