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Healthcare & Wellness
Patient Experience Survey
Measure the full clinic visit — booking ease, wait time, staff courtesy, and whether patients would recommend you.
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What this form looks like
Preview · not interactivePatient Experience Survey
Measure the full clinic visit — booking ease, wait time, staff courtesy, and whether patients would recommend you.
When was your visit?*
Pick a date📅
Which department did you visit?*
Select…▾
Which department was it?
How was each part of your visit?*
PoorFairGoodVery goodExcellentEase of booking the appointmentReception and check-in experienceCourtesy of clinical staff
Roughly how long did you wait past your appointment time?
Pick a date📅
Your best estimate — this is the number we watch most closely.
How would you rate the provider who treated you?*
★★★★★
How likely are you to recommend this clinic to family or friends?*
012345678910
What went well?
What could we do better?
Keep my feedback anonymous
Keep my feedback anonymous
If on, your responses are reviewed without any identifying visit details.
Submit