Patient Feedback Form

Question 1 of 1

Language

Please select your preferred language

Question 2 of 1

Address

Please enter your address

Question 3 of 1

City

Please select your city

Question 4 of 1

Visit Type

How did you receive care today?

Telehealth In-person Remote Monitoring Only

Question 5 of 1

Relationship

What is your relationship to the patient?

Patient Family/Caregiver

Question 6 of 1

Date of Visit

When was your visit?

Question 7 of 1

Overall Experience

How would you rate your overall experience?

😞

1

😐

2

🙂

3

😊

4

😄

5

Question 8 of 1

Appointment Scheduling

Was it easy to get your appointment/reminder?

No Yes

Question 9 of 1

Care Plan Understanding

Did you understand your care plan?

No Yes Partly

Question 10 of 1

Language Support

Did you get help in your preferred language?

No Yes Not needed

Question 11 of 1

Issues Encountered

Any issues today? (Select all that apply)

Waiting time App/portal Device Billing Staff interaction Language Privacy Other

Question 12 of 1

Additional Comments

Please share any additional feedback

Question 13 of 1

Safety Follow-up

Something happened that we should follow up on right away?

Question 14 of 1

Contact Preference

Would you like us to contact you?

No Yes

Question 15 of 1

Preferred Contact Method

How would you prefer to be contacted?

Question 16 of 1

Contact Details

Please provide your contact information

Telehealth Experience

Joining the visit was easy

😞

1

😐

2

🙂

3

😊

4

😄

5

Audio/video quality

😞

1

😐

2

🙂

3

😊

4

😄

5

Wait time before clinician joined

In-Person Experience

Check-in was easy

😞

1

😐

2

🙂

3

😊

4

😄

5

Waiting room time

Staff helpfulness

😞

1

😐

2

🙂

3

😊

4

😄

5

Remote Monitoring Experience

Device setup was easy

😞

1

😐

2

🙂

3

😊

4

😄

5

Daily readings were clear to do

😞

1

😐

2

🙂

3

😊

4

😄

5

Alerts or messages were clear

😞

1

😐

2

🙂

3

😊

4

😄

5

Question 30 of 1

¿Prefirió español durante su atención?

Did you prefer Spanish during your care?

No Sí No fue necesario

Question 31 of 1

¿Faltó algo de traducción?

Was any translation missing?

No Sí

Question 32 of 1

¿Dónde faltó?

Where was it missing?

Optional Question

Net Promoter Score

Would you recommend us?

0

1

2

3

4

5

6

7

8

9

10

Final Question

Privacy Consent

OK to use anonymized feedback to improve care?

Yes, I consent to use anonymized feedback

✅

Thank You!

Your feedback has been submitted successfully. We appreciate your time and input.

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