Patient Feedback Form Template

We care about you, and your opinion.Can you briefly describe what type of treatment you've had?How would you rate the following aspects of your experience with us?

Intake

Communication

Treatment

Staff friendliness

How do you feel we could improve our intake process?What do you think we could do better in our communication?Can you briefly explain how you feel we could improve our care? Do you have recommendations on how our staff could do better next time?Is there have any additional feedback you'd like to share on anything we didn't ask about?We're open to hearing it.Please share your thoughts here on further ways we could improve.Thank you for your time and honesty, it really is invaluable to us.

Collect up to 3.5x more data with Typeform

Feedback makes everyone better

If you’re looking for an easy way to ask your patients for feedback, you’ve found it. This patient feedback form is easy to fill out and will give you honest, focused answers—because it only asks one question at a time.

With Typeform, you can customize everything

Change text, colors, and even logos to match look and feel of your brand. Then embed forms smoothly onto web and email.

Make forms feel effortless to fill out. Pace questions, call people by their name, and adapt the flow based on the data they share.

Stay efficient by connecting forms to your workflow. Typeform integrates with 120+ tools including Slack, Zapier, and HubSpot.

Patient feedback form FAQs:

We’ve all been presented with feedback surveys that were the opposite of inviting. With vague or convoluted questions and the robotic feel of more traditional forms, it can be easy for feedback to feel like no more than a box-ticking exercise. Time for a change.

This patient feedback form asks one question at a time and lets you follow up on ratings with deeper questions. Your patients will feel that their feedback is truly being heard, and you’ll learn a lot in the process.

Before you send out your form, there are two things you should do:

Set up a BAA (Business Associate Agreement) with us

Typeform is a HIPAA-compliant company, so all the healthcare-related info you process with us is legally airtight. But for you to be 100% HIPAA compliant, you’ll first need to set up a BAA. To do this you would need to talk to us about our enterprise plan, which you can do by filling out this Typeform, or contacting your Typeform account manager.

Check the local data collection laws

Data collection laws aren’t a one-size-fits-all thing—especially when there’s sensitive medical info involved. So before hitting share, seek advice from a local lawyer to make sure you’ve covered everything.