Urgent Care Discharge Survey
Please share your feedback about your recent urgent care visit and discharge experience.
Patient Name
*
First Name
Last Name
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall experience during your urgent care visit?
*
1
2
3
4
5
How clearly were your discharge instructions explained to you?
*
Not at all clear
1
2
3
4
Extremely clear
5
1 is Not at all clear, 5 is Extremely clear
Did you receive information about your follow-up care or next steps?
*
Yes
No
Not sure
Were your questions and concerns addressed before discharge?
*
All were addressed
Most were addressed
Some were addressed
None were addressed
Please rate the following aspects of your discharge process:
*
Rows
Friendliness of staff
Wait time for discharge
Explanation of medications
Privacy during discharge
Poor
1
2
3
4
Fair
5
6
7
8
Good
9
10
11
12
Very Good
13
14
15
16
Excellent
17
18
19
20
How likely are you to recommend our urgent care center to others?
*
Not at all likely
0
1
2
3
4
5
6
7
8
9
Extremely likely
10
0 is Not at all likely, 10 is Extremely likely
What could we improve about the discharge process? (Optional)
Age Group
*
Please Select
Under 18
18-29
30-44
45-64
65 or older
Prefer not to say
Gender
*
Female
Male
Non-binary/Other
Prefer not to say
Submit Survey
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