Patient Feedback Form Templates

Published on April 28, 2023
Patient giving his feedback Image Source

What is a Patient Feedback form?

A Patient Feedback form is a tool used by healthcare providers to collect feedback from patients regarding their experiences with the staff, facility, treatment, billing, or any other aspect of their care. This form enables healthcare providers to address concerns, improve the quality of their services, and enhance overall patient satisfaction.

What information can be recorded in a Patient Feedback form?

  1. Submission date: The date when the feedback is submitted by the patient.
  2. Patient name: The full name of the patient providing the feedback.
  3. Patient email: The email address of the patient for follow-up communication, if necessary.
  4. Contact phone: The patient's phone number for additional communication, if necessary.
  5. Feedback category: A dropdown list of feedback categories, including staff, facility, treatment, billing, or other.
  6. Feedback: A detailed description of the patient's feedback, concerns, or suggestions.
  7. Response: The healthcare provider's response to the patient's feedback, if applicable.
  8. Resolved: A dropdown list indicating whether the issue or concern has been resolved, with options for "Yes" or "No."

Benefits of using a Patient Feedback form

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