Patient Satisfaction Survey Template
Collects ratings and comments about a recent visit, plus contact details, for clinics and healthcare practices seeking patient feedback.
When to use it
- After a clinic or practice visit
- To review wait times and staff interactions
- To check whether explanations were clear
- To gather suggestions and referral feedback
What it asks
- Your name
- Email address
- Phone number
- How would you rate your wait time?
- How would you rate our staff?
- How clear were the explanations you received?
- Overall, how would you rate your visit?
- How likely are you to recommend us to others?
- What else would you like us to know?
Why it should be encrypted
Contact details and open comments can reveal a patient's relationship with a practice or include personal health information. Only authorized staff who need the feedback should be able to read answers—not SealForm or unrelated third parties.
Tips
- Make name and contact fields optional if you want more anonymous feedback.
- Avoid asking patients to include detailed medical information in comments.
- Send the survey soon after the visit while details are fresh.