Healthcare
    Survey

    Clinic Feedback Form

    Quick post-visit feedback for OPD and clinics.

    4 questions~3 min

    Free to preview — no account needed. Using it creates your own editable copy.

    Try the template

    These are the real questions. Nothing you answer here is saved or submitted.

    Question 1 of 40%

    Cleanliness*

    About this template

    Clinic Feedback Form is a ready-to-use survey template with 4 questions that takes about 3 minutes to answer. Quick post-visit feedback for OPD and clinics.

    Healthcare templates cover patient satisfaction, discharge follow-up, telemedicine and pharmacy experience. They are deliberately short: a patient completing a survey is often unwell, tired, or waiting for someone else. Keep clinical detail out of the questionnaire and collect only what you will act on — anything identifying belongs in your clinical system, not in a feedback form. Everything in this template is editable — treat the questions below as a starting point that already has the structure right, then cut what does not apply to you.

    Who should use it
    Hospitals, clinics, diagnostic centres, pharmacies and telemedicine providers.
    When to use it
    After discharge, after a consultation, or as a periodic check on a service line.

    What this template helps you measure

    • Cleanliness and safety
    • Staff performance
    • Scored ratings you can trend over time
    • Open-ended feedback in respondents’ own words

    Every question in this template

    4 questions, with what each one is doing there. Change or remove any of them after you make your copy.

    1. Cleanliness*

      Star rating

      Why this matters: Turns an impression of cleanliness and safety standards into a score, which is what lets you tell a genuine dip apart from a bad week of memories.

    2. Doctor's explanation*

      Star rating

      Why this matters: Scoring how your people performed separately stops one weak area from being averaged away inside a single overall rating.

    3. Front desk experience*

      Star rating

      Why this matters: A scored answer is the part of this template you can chart — the open questions explain the movement, this one detects it.

    4. Anything to share?

      Long text

      Why this matters: Open text is where the reason behind the scores shows up. This is the question that produces the quotes worth taking into a review meeting.

    How to use this template

    1. 1

      Start with the template

      Click "Use this template" and SurveyKar creates your own copy of Clinic Feedback Form, with every question already in place. The original template stays untouched.

    2. 2

      Customise the questions

      Reword anything that does not match your business, delete what you do not need, change a question type, or add your own. Shorter surveys finish more often — cut before you add.

    3. 3

      Add your branding

      Set your logo, brand colours, fonts and background so the page looks like it belongs to you rather than to a survey tool.

    4. 4

      Share it

      Publish, then share the link, print the QR code, embed it on your site, or send it to a contact list over email or WhatsApp.

    5. 5

      Read the responses

      Results land in your dashboard as they arrive, with charts per question, filters, sentiment analysis on open text, and CSV or PDF export.

    What you can customise

    Your copy is yours. Nothing in the template is locked, and the original is never changed by anything you do.

    Questions and wording

    Edit, reorder, delete or add questions. Nothing in the template is locked.

    Question types

    Swap a rating for NPS, a single choice for a matrix, or add ranking, sliders and file uploads.

    Logo and brand colours

    Apply your logo, primary colour, fonts and background image to the respondent page.

    Conditional logic

    Skip questions or branch to a different page based on an earlier answer. Available on the Basic plan and above.

    Thank-you page

    Write your own closing message, or redirect respondents to a URL of your choice after submitting.

    Sharing and distribution

    Share by link or QR code, embed it on your website, or send it out over email and WhatsApp campaigns.

    Frequently asked questions

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    Ready to create your survey?

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