Patient Feedback Form Template for Clinics and Hospitals

Please rate your overall experience at [Hospital/Clinic Name]:, Reception/Check-in process:, Waiting time:, Cleanliness of the facility:, Courtesy and professionalism of staff (Receptionists, Nurses, Doctors, etc.), Communication with your doctor (Explanation of diagnosis, treatment options, etc.), Quality of medical care received, Quality of medical care received, Clarity of discharge instructions (if applicable), Billing process, Overall comfort of the facility, Would you recommend [Hospital/Clinic Name] to your friends and family?

What did you appreciate most about your visit? (e.g., specific staff members, services, or aspects of your care), What areas could we improve?, Did you encounter any problems during your visit? If so, please describe them., If you answered no to the previous question, why?

Start Date & End Date