Healthcare Patient Satisfaction Survey Response
Patient Information
Full Name
Email Address
Date of Visit
Overall Experience
How would you rate your overall experience?
1
2
3
4
5
Reason for Visit
Staff & Facility
Friendliness of staff
1
2
3
4
5
Cleanliness of facility
1
2
3
4
5
Wait Time
Very short
Short
Average
Long
Very long
Care & Communication
Quality of care received
1
2
3
4
5
Explanation of condition and treatment
1
2
3
4
5
Final Thoughts
Would you recommend our facility to others?
Yes
No
Not sure
Additional Comments or Suggestions