Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Patient Satisfaction Survey
Patient Satisfaction Survey We value your feedback! Please take a moment to complete this survey.
Overall experience
- Very Satisfied
- Satisfied
- Neutral
- Dissatisfied
- Very Dissatisfied
Quality of care
- Very Satisfied
- Satisfied
- Neutral
- Dissatisfied
- Very Dissatisfied
Wait time
- Very Satisfied
- Satisfied
- Neutral
- Dissatisfied
- Very Dissatisfied
Friendliness of staff
- Very Satisfied
- Satisfied
- Neutral
- Dissatisfied
- Very Dissatisfied
Comments or suggestions
Would you recommend our clinic to others?
- Yes
- No
Patient Satisfaction Survey template from formisoft.com. formisoft.com/intake-templates/patient-satisfaction-survey