Patient Telehealth Service Poll Form
Please help us improve our telehealth services by sharing your feedback. Your responses are anonymous and valuable.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Age Group
*
Please Select
Under 18
18-29
30-44
45-59
60+
Prefer not to say
Gender
Female
Male
Non-binary/Other
Prefer not to say
How would you rate your overall experience with our telehealth service?
*
1
2
3
4
5
Please rate the following aspects of your telehealth visit:
*
Rows
Very Poor
Poor
Fair
Good
Excellent
Ease of scheduling appointment
1
2
3
4
5
Clarity of communication with provider
6
7
8
9
10
Audio/video quality
11
12
13
14
15
Privacy and confidentiality
16
17
18
19
20
Provider's ability to address your concerns
21
22
23
24
25
Did you experience any technical difficulties during your telehealth visit?
*
Yes
No
If you experienced technical difficulties, please describe them:
How likely are you to use telehealth services again in the future?
*
Not likely
1
2
3
4
Very likely
5
1 is Not likely, 5 is Very likely
Do you have any suggestions for improving our telehealth services?
Submit Feedback
Should be Empty: