Patient Wait Time Assessment
Help us improve your healthcare experience by evaluating your recent visit and wait time.
Full Name
*
First Name
Last Name
Contact Email
example@example.com
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Department or Clinic Visited
*
Please Select
General Medicine
Pediatrics
Dermatology
Orthopedics
Cardiology
Other
Reason for Visit
*
Please Select
Routine Check-up
Follow-up Appointment
Acute Illness/Symptoms
Lab Work/Tests
Other
How long did you wait before being seen by a healthcare provider?
*
Less than 15 minutes
15–30 minutes
31–60 minutes
More than 1 hour
Please rate the following aspects of your waiting experience:
*
Rows
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
Ease of check-in process
1
2
3
4
5
Clarity of wait time information
6
7
8
9
10
Comfort of waiting area
11
12
13
14
15
Staff courtesy during wait
16
17
18
19
20
Updates provided during wait
21
22
23
24
25
Overall, how satisfied were you with the wait time during your visit?
*
1
2
3
4
5
Did you feel your wait time was reasonable for your visit?
*
Yes
No
Would you like to provide any additional comments or suggestions to help us improve?
Submit Assessment
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