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Patient Feedback · Popular

Improve Urgent Care with Patient Feedback Forms

Gather meaningful patient feedback on urgent care visits, wait times, provider communication, and clinic experience to drive continuous improvement.

Use This Template Free Preview

Neo theme

formbuilder.ai/f/urgent-care-clinic-visit-experience-provider-communication-patient-feedback-form

Urgent Care Clinic Visit Experience & Provider Communication Patient Feedback Form

Patient Name

· · ·

Email Address

· · ·

Phone Number

· · ·

Submit

The Urgent Care Clinic Visit Experience & Provider Communication Patient Feedback Form is designed to help urgent care clinics systematically collect patient insights on every aspect of their visit — from check-in to discharge. It captures ratings on wait times, facility cleanliness, and the overall visit experience, giving clinic administrators actionable data to enhance service delivery.

This template is ideal for urgent care centers, walk-in clinics, and healthcare administrators who want to monitor provider performance and patient satisfaction. It includes dedicated sections for evaluating how clearly providers communicate diagnoses, treatment options, and discharge instructions, as well as how empathetic and respectful they are during consultations.

By using this ready-to-deploy form, clinics can identify pain points, recognize top-performing staff, and make evidence-based improvements to patient care. The customizable fields make it easy to tailor the form to your clinic's specific needs, helping you build trust and loyalty among your patient community.

3 Pages

21 Questions

~7min To complete

Free No credit card needed

Field types Likert Scale ×6 Star Rating ×3 Single Choice ×2 Long Text ×2 Full Name Email Phone Date Dropdown Short Text NPS Score Multiple Choice

Questions in this template

Free template

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

Page 1 Visit Details 7 questions

Your Urgent Care Visit Information

1 Patient Name * Full Name

2 Email Address Email

3 Phone Number Phone

4 Date of Visit * Date

5 Clinic Location Visited * Dropdown

6 Reason for Visit * Short Text

7 Is this your first visit to this clinic? * Single Choice

Page 2 Visit Experience & Provider Communication 9 questions

Rate Your Visit Experience

1 Overall satisfaction with your visit * Star Rating

2 Wait time from check-in to being seen was acceptable * Likert Scale

3 The check-in process was smooth and efficient * Likert Scale

4 The facility was clean and comfortable * Likert Scale

Provider Communication

5 How well did your provider explain your diagnosis? * Star Rating

6 How well did your provider listen to your concerns? * Star Rating

7 The provider communicated treatment options clearly * Likert Scale

8 The provider showed empathy and respect * Likert Scale

9 Discharge instructions were easy to understand * Likert Scale

Page 3 Overall Feedback 5 questions

Additional Feedback & Recommendations

1 How likely are you to recommend this urgent care clinic to family or friends? * NPS Score

2 Which areas could be improved? Multiple Choice

3 Please share any additional comments about your experience Long Text

4 Is there anything specific a staff member did that you'd like to recognize? Long Text

5 May we contact you to follow up on your feedback? Single Choice

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.