Collect feedback after a clinic visit. Covers scheduling, wait time, care team communication, facility and accessibility, with an optional follow-up request.
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Date of visit
Location / Clinic
Department / Service
Type of visit
How did you schedule your appointment?
Overall satisfaction with your visit
How likely are you to recommend our clinic to friends or family?
Ease of scheduling
Wait time before being seen
Courtesy and professionalism of staff
Provider listened carefully to my concerns
Provider explained things in a way I could understand
I felt involved in decisions about my care
Instructions for next steps (medications, follow-up, tests) were clear
Cleanliness of the facility
Comfort of waiting and exam areas
Privacy during my visit
Which areas could we improve? (Select all that apply)
What went well during your visit?
What could we improve for next time?
Any additional comments or suggestions
Would you like our team to follow up with you about your feedback?
Your name (optional)
Preferred contact method (email or phone)
Best time to contact you (optional)
Patient Feedback Form
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