Telehealth Appointment Delay Report Form
Report delays experienced during your telehealth appointment to help us improve service quality.
Patient Full Name
*
First Name
Last Name
Patient Email Address
*
example@example.com
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Provider or Clinic Name
*
Date of Telehealth Appointment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Scheduled Appointment Type
*
Please Select
Consultation
Follow-up
Prescription Renewal
Lab Results Review
Other
How long was the delay?
*
Please Select
Less than 10 minutes
10–20 minutes
21–30 minutes
More than 30 minutes
Who experienced the delay?
*
Patient
Provider
Both
Reason for the delay (if known)
*
Please Select
Technical issues (internet, platform, etc.)
Provider running late
Patient running late
Scheduling confusion
Other/Not sure
Please describe the delay and any impact it had on your care.
*
Have you contacted the provider or clinic regarding the delay?
*
Yes
No
Preferred follow-up method (if needed)
Email
Phone
Submit Report
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