Patient Discharge Feedback Form
Please provide your feedback regarding your recent discharge from our facility.
Full Name
First Name
Last Name
Date of Discharge
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall Satisfaction with Care Received
1
2
3
4
5
Were your discharge instructions clear and easy to understand?
Yes
No
Somewhat
How would you rate the communication with the healthcare staff?
1
2
3
4
5
Please provide any additional comments or suggestions
Submit
Should be Empty: