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  4. Patient Feedback Form

Patient Feedback Form

Gather patient feedback after a visit — on experience, treatment, communication and staff — to keep improving care.

Description

A patient feedback form captures how a visit felt from the patient’s side, once they’ve left. Beyond the clinical outcome, it surfaces the things that shape their experience — how they were treated, how clearly staff communicated, and whether anything went wrong — so your practice can keep raising the standard of care.

It measures overall experience and satisfaction with both treatment and communication, asks whether the patient faced any issues with room to describe them, and which staff or services they interacted with. A note on who helped most and an open comments field turn quiet impressions into useful feedback.

Customize the questions to match your practice, restyle it in your brand colors, and embed it on your site or a follow-up email so feedback arrives fresh.

Form fields

Everything the Patient Feedback Form above collects — 10 fields, so you can see exactly what it captures before you make it your own.

We’d love your feedback

  • How was your overall experience?

    Short Answer Icon
    Short Answer

  • How satisfied are you with the treatment you received?

    Short Answer Icon
    Short Answer

  • How satisfied were you with the communication from our staff?

    Scale Icon
    Scale

  • Did you face any issues today?

    Yes/No Icon
    Yes/No

  • Please describe the issue:

    Long Answer Icon
    Long Answer

  • Which of the following did you interact with?

    Multi-Select Icon
    Multi-Select

  • Who helped you the most?

    Short Answer Icon
    Short Answer

  • Any additional comments?

    Long Answer Icon
    Long Answer

  • What's your name?

    Name Icon
    Name

  • Email (optional)

    Email Icon
    Email
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Template FAQs

Common questions about the Patient Feedback Form — what it captures, when to use it, and how to make it your own.

What is a patient feedback form?

It’s a form practices send after a visit to capture the patient’s experience. It measures satisfaction with treatment and communication and surfaces any issues, so you learn what’s working and where care could improve, from the people who actually received it.

What does the form ask?

Overall experience, satisfaction with treatment and with staff communication, whether the patient faced any issues with space to describe them, and which staff or services they interacted with. A note on who helped most and an open comments field complete it.

When should you send it?

Soon after the visit, while it’s fresh in the patient’s mind. Prompt feedback captures an accurate impression, catches any problem early enough to put right, and shows patients you care about their experience, not just the appointment itself.

Who is this form for?

GP practices, clinics and healthcare teams who want to measure and improve patient experience, and the patients sharing it. It suits any provider that treats good care as more than clinical outcomes and wants honest, specific feedback it can act on.

Why ask which staff the patient saw?

Tying feedback to the staff or service involved turns a general rating into something you can act on — recognizing people doing great work and spotting where support is needed. It makes praise and problems specific rather than a vague practice-wide average.

Is this feedback form free to use?

Yes — it’s free. Create a Fun Forms account, customize the questions to match your practice, restyle it to your brand, and embed it on your website with no coding. Responses then collect in one place, ready to act on and improve care.

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