Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Provider Rating Survey
Provider Name
Visit Date
____ / ____ / ________
Listening and Attentiveness
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Explanation Clarity
- Very clear
- Mostly clear
- Somewhat unclear
- Not clear
- Not applicable
Time Spent with Patient
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Empathy and Bedside Manner
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Shared Decision-Making
- Excellent
- Good
- Fair
- Poor
- Very poor
- Not applicable
Confidence in Provider
- Very confident
- Somewhat confident
- Not confident
- Need more information
Would Recommend Provider
- Yes
- No
- Not sure
- Not applicable
Additional Feedback
Provider Rating Survey template from formisoft.com. formisoft.com/intake-templates/provider-rating-survey