Emergency Room Visit Feedback Form
Date of Visit
Time of Visit
Reason for Visit
Wait Time
Less than 15 minutes
15-30 minutes
30-60 minutes
More than 1 hour
How would you rate the quality of care you received?
Excellent
Good
Fair
Poor
Staff Professionalism
Excellent
Good
Fair
Poor
Facility Cleanliness
Excellent
Good
Fair
Poor
Additional Comments