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Patient Feedback · Popular

Improve Care with Patient Experience Feedback

Gather honest post-visit patient feedback on scheduling, wait times, staff, and care quality to continuously improve your healthcare services.

Use This Template Free Preview

Peach theme

formbuilder.ai/f/post-visit-patient-experience-satisfaction-feedback-form

Post-Visit Patient Experience & Satisfaction Feedback Form

Patient Full Name

· · ·

Email Address

· · ·

Phone Number

· · ·

Submit

The Post-Visit Patient Experience & Satisfaction Feedback Form is designed to help healthcare facilities collect meaningful, structured feedback from patients following their appointments. It covers every key touchpoint of the patient journey, including appointment scheduling, wait times, staff courtesy, provider communication, and facility cleanliness.

This template is ideal for hospitals, clinics, private practices, and specialty departments seeking to monitor and improve the quality of care they deliver. By capturing ratings on specific aspects of the visit alongside open-ended responses, providers gain actionable insights that drive real improvements in patient satisfaction and outcomes.

With built-in NPS-style recommendation questions and resolution tracking, this form gives your team a comprehensive view of the patient experience. Easy to customize and deploy, it helps you stay compliant, patient-focused, and committed to continuous improvement in healthcare delivery.

3 Pages

21 Questions

~7min To complete

Free No credit card needed

Field types Likert Scale ×6 Long Text ×3 Single Choice ×2 Full Name Email Phone Date Dropdown Short Text Star Rating NPS Score Yes / No singlecheckbox

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Patient & Visit Details 7 questions

Patient & Visit Details

1 Patient Full Name * Full Name

2 Email Address Email

3 Phone Number Phone

4 Date of Visit * Date

5 Department / Clinic Visited * Dropdown

6 Name of Attending Physician or Provider Short Text

7 Type of Visit * Single Choice

Page 2 Your Experience & Satisfaction 8 questions

Rate Your Experience

Please reflect on your most recent visit and rate each aspect of your experience honestly. Your feedback helps us improve the quality of care we provide.

1 The appointment scheduling process was easy and convenient * Likert Scale

2 Wait time before being seen was reasonable * Likert Scale

3 The staff were courteous, professional, and helpful * Likert Scale

4 My provider listened carefully and addressed my concerns * Likert Scale

5 My treatment plan and next steps were clearly explained * Likert Scale

6 The facility was clean, comfortable, and well-maintained * Likert Scale

7 Overall Satisfaction with Your Visit * Star Rating

8 How likely are you to recommend our facility to friends or family? * NPS Score

Page 3 Additional Comments 6 questions

Tell Us More

1 Was your health concern resolved or adequately addressed during this visit? * Single Choice

2 What did we do well during your visit? Long Text

3 What could we improve to make your experience better? Long Text

4 Any additional comments, concerns, or suggestions? Long Text

5 Would you like someone from our patient relations team to follow up with you? Yes / No

6 I consent to my feedback being used anonymously for quality improvement purposes * singlecheckbox

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.