Healthcare Outpatient Feedback Questionnaire
Please help us improve our services by sharing your feedback about your recent outpatient visit.
Full Name
*
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
Orthopedics
Cardiology
Dermatology
Other
How would you rate the following aspects of your visit?
*
Rows
Excellent
Good
Fair
Poor
Ease of making appointment
1
2
3
4
Staff courtesy and professionalism
5
6
7
8
Provider communication and explanation
9
10
11
12
Wait time before being seen
13
14
15
16
Cleanliness of facility
17
18
19
20
Overall satisfaction with your visit
*
1
2
3
4
5
Was your concern or issue addressed during your visit?
*
Yes
Partially
No
Would you recommend our facility to others?
*
Yes
Maybe
No
Please share any additional comments or suggestions
Submit Feedback
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