Telemedicine Service Quality Report Form
Report and evaluate your telemedicine consultation experience to help us improve our services.
Patient Initials
*
Date of Telemedicine Consultation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Healthcare Provider
*
Type of Consultation
*
Please Select
General Medical Advice
Follow-up Appointment
Specialist Consultation
Prescription Renewal
Mental Health Counseling
How would you rate the technical quality (audio/video/connectivity)?
*
1
2
3
4
5
How clearly did the provider communicate with you?
*
Very clear
Mostly clear
Somewhat clear
Unclear
Was the consultation on time?
*
Yes, started on time
Started a few minutes late
Started more than 10 minutes late
Did not start
Overall, how satisfied are you with this telemedicine consultation?
*
1
2
3
4
5
Did you experience any technical issues?
*
Audio problems
Video problems
Connectivity issues
No issues
Please describe any specific issues or concerns experienced during your consultation.
Is any follow-up needed?
*
No follow-up needed
Provider to contact me
I will schedule another appointment
Other
Submit Report
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