Patient Referral Process Survey Form
Please share your feedback on the patient referral process. Your responses will help us improve our services. All questions are about your experience with the referral process.
How satisfied are you with the overall patient referral process?
*
1
2
3
4
5
How easy was it to initiate a referral?
*
Very easy
Somewhat easy
Neutral
Somewhat difficult
Very difficult
Did you receive clear instructions on how to complete the referral?
*
Yes, completely clear
Somewhat clear
Not clear
How would you rate the communication between providers during the referral process?
*
1
2
3
4
5
How timely was the referral process?
*
Very timely
Somewhat timely
Neutral
Somewhat delayed
Very delayed
Please indicate your agreement with the following statements about the referral process:
*
Rows
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The referral process was straightforward
1
2
3
4
5
I felt supported throughout the process
6
7
8
9
10
I would recommend this referral process to others
11
12
13
14
15
What was the most helpful part of the referral process?
What could be improved in the referral process?
Would you like to be contacted for follow-up about your feedback?
Yes
No
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