Templates · Free template · Feedback
Patient Feedback Survey Template
A short printable patient feedback survey that scores the parts of a visit that matter most and leaves room for comments, so you learn what to fix while it is still fresh.
Ask less, and ask straight after
Short surveys sent within a day of the visit get answered. Ask about the booking experience, the care, the staff, and the environment, and finish with a single recommend question and one open comment.
Read every response. A pattern of small complaints, such as waiting time or unclear aftercare, is the cheapest source of improvements you have.
Patient Feedback Survey
Visit
Ratings (1 to 5)
1 = poor, 5 = excellent.
| Question | Rating |
|---|---|
| Ease of booking | |
| Wait time | |
| Friendliness of staff | |
| Explanation of your treatment | |
| Comfort and cleanliness | |
| Overall satisfaction |
Comments
- You may contact me about my feedback
- You may share my comments
Template from zdrovia.ca/templates/patient-feedback-survey-template/ · Review with your medical director, regulatory college guidance, and insurer before use.
Send this form before the appointment instead of printing it
Zdrovia's form builder turns this template into a digital form your clients sign on their own phone. The signed copy files into their chart with the exact version they saw, and photo consent stays separate from treatment consent. It's free for solo practitioners, with data stored in Canada.
See how Zdrovia is set up for solo practices.
Frequently asked questions
How long should a survey be?
Under two minutes. Fewer than ten questions is a good rule.
Can I use feedback in marketing?
Only with the patient's permission, and never edit it to change its meaning.
Related
This template is a starting point for discussion with your team and advisors, not legal or medical advice. Requirements vary by province and profession. Have your medical director, your regulatory college's guidance, and your malpractice insurer confirm the wording before you use it with patients.