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Practice name: ______________________________

Wait Time Feedback Survey

Appointment Time

Arrival to Check-In Wait

  • Less than 5 minutes
  • 5–15 minutes
  • 16–30 minutes
  • More than 30 minutes
  • Not sure

Check-In to Exam Room Wait

  • Less than 5 minutes
  • 5–15 minutes
  • 16–30 minutes
  • More than 30 minutes
  • Not sure

Exam Room to Provider Wait

  • Less than 5 minutes
  • 5–15 minutes
  • 16–30 minutes
  • More than 30 minutes
  • Not sure

Were You Informed of Delays

  • Yes
  • No
  • Not sure

Wait Time Acceptability

  • Acceptable
  • Longer than expected
  • Much longer than expected

Impact on Overall Experience

Suggestions to Reduce Wait

Survey Date

____ / ____ / ________

Would You Recommend Us?

  • Yes
  • No
  • Not sure

Wait Time Feedback Survey template from formisoft.com. formisoft.com/intake-templates/wait-time-survey

Wait Time Feedback Survey (printable) | Formisoft | Formisoft