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Feedback & CX
Patient Experience Survey
Post-visit feedback for clinics and practices — communication, wait times, and facility quality, with privacy-safe consent.
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What this form looks like
Preview · not interactivePatient Experience Survey
Post-visit feedback for clinics and practices — communication, wait times, and facility quality, with privacy-safe consent.
What kind of visit was it?*
Select…▾
Roughly how long did you wait past your appointment time?
Select…▾
The provider listened carefully to my concerns*
Strongly disagreeDisagreeNeutralAgreeStrongly agreeRow ARow B
Explanations about my care were clear and easy to follow*
Strongly disagreeDisagreeNeutralAgreeStrongly agreeRow ARow B
I was treated with courtesy and respect*
Strongly disagreeDisagreeNeutralAgreeStrongly agreeRow ARow B
How clean and comfortable was the facility?
★★★★★
How likely are you to recommend this provider to family or friends?*
Not at all likelyExtremely likely
Anything else about your visit? (optional)
Please avoid including personal health details — this survey is anonymous.
How we use your feedback*
How we use your feedback
Submit