Patient Exit Survey Template

Before you leave, please take a few moments to complete this brief survey. Your responses help us improve the care we provide.
1.
How satisfied were you, overall, with the care you received today?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
2.
Rate your experience on a 1 to 5 scale (1 = lowest, 5 = highest):
1
5
3.
Were the staff friendly and attentive?
Yes
Not sure
No
Other
4.
If you have any other comments or suggestions, please share them below:
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