Templates/Forms/Patient Satisfaction Survey

ConversationalHealthcare

Patient Satisfaction Survey

Improve patient retention with care quality ratings, staff feedback, and facility assessments

11fields

3pages

4-6 minutes

patientsatisfactionfeedbacksurvey

Browse More Templates

uplup.com/p/g7zkr6wa

Live interactive preview - try it out!

What's Included in This Template

11 Fields

Pre-configured fields with the right input types, validation, and layout for healthcare.

Full Customization

Change colors, fonts, add your logo, rearrange fields, and make it match your brand perfectly.

60+ Integrations

Connect with Mailchimp, HubSpot, Zapier, Google Sheets, Slack, and more. Automate your workflow.

Form Structure

Cover Page

Page 1

Page 2

Thank You Page

In conversational mode, each field becomes its own page for a focused experience.

About This Template

Understanding how patients perceive their care experience is essential for improving retention, boosting online reviews, and meeting quality benchmarks that affect reimbursement rates. A patient satisfaction survey captures structured feedback on every touchpoint, from scheduling and check-in to provider interaction and follow-up, so your leadership team can identify what is working and where gaps exist.

Uplup's patient satisfaction survey template covers key dimensions including ease of scheduling, wait times, staff friendliness, provider communication, facility cleanliness, and likelihood to recommend. Rating scales and open-ended comment fields give you both quantifiable scores and actionable narrative feedback. Conditional logic lets you tailor follow-up questions based on how a patient rates each area, so low scores trigger prompts for specific improvement suggestions.

Hospitals, outpatient clinics, dental offices, and behavioral health practices use this survey to track satisfaction trends over time. Results feed into your dashboard where you can filter by provider, location, or date range, making it straightforward to pinpoint departments that need attention and celebrate teams that consistently deliver outstanding patient experiences.

Who Is This Template For?

This template works for a wide range of goals and industries.

Post-Visit Feedback Collection

Send the survey link in a follow-up email or text message within 24 hours of each patient visit. Timely distribution captures fresh impressions and yields higher response rates than surveys sent days or weeks later.

Provider Performance Benchmarking

Filter survey results by individual provider to compare satisfaction scores across your practice. Identify providers who excel at communication and those who may benefit from additional patient interaction training.

Quality Improvement Initiatives

Healthcare organizations pursuing accreditation or value-based care contracts can use survey data to document patient experience metrics. Trend reports show improvement over time, supporting compliance with CMS and Joint Commission requirements.

Multi-Location Performance Comparison

Health systems with multiple sites can deploy the same survey across all locations and compare results side by side. Identify which facilities lead in patient satisfaction and replicate their best practices organization-wide.

Key Features

Likert Scale Rating Questions

Patients rate their experience on a consistent scale across multiple dimensions, from scheduling ease to provider communication. Standardized scales produce data you can trend over months and compare across departments.

Conditional Follow-Up for Low Scores

When a patient rates any category below a threshold you set, the form displays an open-ended field asking what could be improved. This gives your team specific, actionable feedback instead of generic low scores.

Net Promoter Score Question

A built-in NPS question asks patients how likely they are to recommend your practice on a 0 to 10 scale. Track your NPS over time to gauge overall patient loyalty and benchmark against industry averages.

Anonymous Submission Option

Toggle the form to allow anonymous responses, encouraging patients to share candid feedback without concern about affecting their care. You still capture the data you need without requiring identifying information.

Response Dashboard with Trend Filtering

View all survey responses in a dashboard with filters for date range, provider, location, and score thresholds. Export data to CSV for deeper analysis or integration with your quality improvement reporting tools.

How It Works

Choose This Template

Click "Use This Template Free" to get started. You will get a full copy of this form in your account, ready to edit.

Customize It

Edit the fields, update the design, add your branding, and set up integrations. Everything is editable from the visual builder.

Share & Collect Responses

Publish your form and share it with a link, embed it on your website, or post it on social media. View responses in real time.

Frequently Asked Questions

When is the best time to send this survey to patients?

Research shows that surveys sent within 24 to 48 hours of the visit yield the highest response rates and most accurate feedback. You can include the survey link in post-visit emails or text messages triggered by your scheduling system.

Can patients complete the survey anonymously?

Yes. You can configure the form to omit name and contact fields, allowing fully anonymous submissions. This often increases candor and response rates, especially for sensitive topics like provider communication or billing concerns.

How do I track satisfaction trends over time?

Each submission is timestamped in your Uplup dashboard. Export monthly or quarterly data to a spreadsheet to chart trends in overall satisfaction, individual question scores, and NPS. This makes it simple to measure the impact of improvement initiatives.

Can I customize the rating scale?

Absolutely. The template defaults to a five-point Likert scale, but you can switch to a seven-point scale, star ratings, or emoji-based responses. Adjust labels to match your preferred language, such as Poor to Excellent or Strongly Disagree to Strongly Agree.

Does this survey include a Net Promoter Score question?

Yes. The template includes a standard NPS question asking patients to rate their likelihood of recommending your practice on a 0 to 10 scale. You can segment respondents into promoters, passives, and detractors to calculate your score.

Can I compare results across multiple providers or locations?

Add a question asking patients to select their provider or location. Then use the dashboard filters to view results for each segment separately. This lets you benchmark performance and identify where targeted improvements will have the greatest impact.

Related Templates

Explore more form templates you might like.

Ready to Use This Form Template?

Customize the fields, add your branding, set up integrations, and start collecting responses today.