Patient Satisfaction Survey templatePRO: uses NPS, publishing needs a Pro plan

An anonymous patient satisfaction survey combining three measures that answer different questions: a star rating for the overall visit, a five-row matrix grading scheduling, wait time, front-desk courtesy, provider time, and clarity of next steps, and an NPS question for the recommend-to-family signal. One open question closes it: what's one thing we could do better.

Use this template Start free — no card

5 questions · Pro to publish · fully customizable

Uses an NPS question (Pro). You can preview and edit it on Free; publishing needs Pro — or swap the NPS question for a 0–10 rating to publish on Free.

Interactive — fill it in like a respondent would.Open full width

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01What type of visit did you have?Multiple choice

02Overall, how would you rate your visit?Star rating

03How did we do on each of the following?Matrix

04How likely are you to recommend us to family or friends?NPS score

05What's one thing we could do better?Long text

When to use this template

A clinic sending a two-minute survey after each visit and watching the matrix rows to see which part of the experience slips first
A multi-provider practice comparing satisfaction across in-person, telehealth, urgent, and lab-only visits using the visit-type question
A practice manager who needs a defensible patient-satisfaction number for quarterly reporting, and gets both stars and NPS from one form
A newly opened office establishing a baseline before making front-desk staffing changes

Tips to get more from it

The matrix rows are chosen so each maps to something fixable — scheduling, wait time, courtesy, provider time, next-step clarity. If you add rows, keep that property
The visit-type question makes segmentation possible in the CSV export: filter telehealth visits against in-person before drawing conclusions from the averages
The welcome copy promises anonymity, so don't add name or email fields without rewriting it — and the ending already redirects urgent matters to a phone call, which matters on an anonymous form
The NPS field requires the Pro plan to publish; if you're on free, delete it and lean on the star rating and matrix, which publish free

Questions people ask

Is this patient survey really anonymous?

The template collects no name, email, or contact fields, and its welcome text says so. If you edit the form, keeping it free of identifying fields is what keeps that promise true.

Can I track satisfaction scores over time?

Yes — responses accumulate in your dashboard and export as CSV with each matrix row, the star rating, and NPS in separate columns, so you can chart monthly averages in a spreadsheet.

Do I need a paid plan for the NPS question?

Publishing a form with an NPS field requires Pro at $14.99/mo. The star rating and matrix work on the free plan, so you can run the survey without NPS at no cost.