Patient satisfaction survey form
A satisfaction survey captures feedback while the visit is fresh. A 0-10 satisfaction rating pairs with two optional open questions — what went well and what could improve — so the clinic understands why the score is what it is. This is feedback collection, not a medical record or complaint resolution system.
The form beside this text is live. Fill it in and submit it — it validates exactly as it would for a real respondent, and saves nothing.
Satisfaction as a 0-10 slider, not free text
A slider field gives the clinic structured scores that can be averaged and trended. Free text produces "very happy", "decent", "not great", which is subjective and cannot be averaged or compared across time.
Two optional open questions for context
A score without a reason is only half the feedback. The two optional text fields — what went well and what could improve — let the patient explain the score so the clinic knows what to act on.
No card required.
Patient Satisfaction Survey Form
Live previewHow to build this form
5 steps in the editor. Nothing here needs a paid plan.
- Add a date field for the visit date, so the clinic can match feedback to specific appointments.
- Add an optional text field for the provider name if the patient remembers it, to route feedback to the right person.
- Add a slider field for satisfaction rating, set to 0-10 in the settings, so the clinic sees structured scores.
- Add two optional long text fields — one asking what went well, one asking what could improve — to capture the driver behind the score.
- In Settings, export to CSV monthly to review trends and see which providers or areas get the highest marks.
Fields in this form
5 fields, using 4 of the 19 field types available.
| Question | Field type | Required |
|---|---|---|
| Visit date | Date | Yes |
| Provider name (if you remember it) | Short text | Optional |
| How satisfied were you with your visit? (0 = very unsatisfied, 10 = very satisfied) | Slider | Yes |
| What went well? | Long text | Optional |
| What could we improve? | Long text | Optional |
What goes wrong with this form
Specific to a patient satisfaction survey form, not general advice about forms.
Treating the survey as a complaint resolution system
A survey collects feedback. It does not trigger a response or resolve complaints automatically. If a patient has an urgent concern or complaint, they should contact the clinic directly by phone. The survey is for after-visit feedback that helps improve future care, not for resolving current problems.
Satisfaction as a text field
Use a slider field set to 0-10 rather than asking "how satisfied were you". A number — 7, 8, 3 — is objective and can be averaged and trended; free text produces "pretty satisfied", "not really", which cannot be averaged.
No optional questions for context
A score alone is incomplete. Add two optional open questions — what went well and what could improve — so the clinic understands why the patient gave that score. A high score with feedback on what could improve is more actionable than just a high number.
Questions about this form
Is a patient satisfaction survey the same as a medical record?
No. This survey collects feedback about the visit experience — satisfaction, what went well, what could improve. It is not a medical document and does not replace or become part of the patient's medical record. The survey is feedback only.
Who sees my satisfaction feedback?
The clinic staff who manage patient experience and quality improvement use the surveys to identify trends and improve care. Individual responses may be reviewed by the provider you saw if there's specific feedback. Your identity is known to the clinic but your response is kept separate from other records.
What happens if I give a low satisfaction score?
Low satisfaction scores help the clinic identify problems and improve. The survey alone does not trigger anything automatically. The clinic uses survey trends to decide where to focus. If you have an urgent complaint, contact the clinic directly by phone rather than waiting for the survey results.
Other templates
- Patient intake formInsurance provider and ID as their own fields, so registering doesn't start with a phone call.
- Appointment Request FormCollect a preferred date, time and reason for visit for clinics, salons and studios.
- Medical HistoryCollect a new patient's medical background before the first appointment.