Patient Satisfaction Survey Template
A one-page survey your patients can finish in the waiting room. It covers getting an appointment, wait time, how the provider communicated, the front desk, and an overall rating, with space for comments. Edit the wording, then print blank copies.
Edit the practice details and wording, then print blank copies for the waiting room. Boxes print empty for patients to tick; click one on screen only to preview a filled form.
Patient Satisfaction Survey
Anonymous unless you choose to add your name — please return at the front desk or by mail
1.About your visit
2.Getting care
3.Your provider
4.Office staff
5.Overall
6.Your comments
Please do not include medical details. If you want us to contact you about a concern, add your name and phone number.
Thank you. Your answers are used only to improve our service and are reviewed by the practice manager. Completing this survey is voluntary and does not affect your care.
What Should a Patient Satisfaction Survey Ask?
Ask about things the patient actually saw and can judge: how easy it was to get an appointment, how long they waited, whether the provider explained things clearly and listened, and how the front desk treated them. Keep it to one page so people finish it in the waiting room.
The template follows the same themes as the federal standard for outpatient care. AHRQ's CAHPS Clinician & Group Survey (CG-CAHPS) asks patients to report on their experiences with providers and staff in primary and specialty care, and AHRQ notes the results can be used to decide where improvement is needed and to measure whether changes worked. If a payer or program requires the official CG-CAHPS instrument, use that version; this template is for practices running their own internal survey.
Are Patient Satisfaction Surveys Allowed Under HIPAA?
Yes. Using patient contact details to ask about their experience is a health care operations activity: the Privacy Rule's definition of health care operations starts with “conducting quality assessment and improvement activities” (45 CFR 164.501), so no patient authorization is needed. A few rules still apply:
- If you send the survey through an online form tool, the vendor holds PHI and needs a signed BAA. Compare options in our HIPAA-compliant survey tools review.
- Keep completed paper surveys with the same care as other patient documents, and shred them when you are done.
- Do not ask for diagnoses or treatment details. You do not need them to measure service, and leaving them out keeps the survey simple to store.
Running the Survey Without Skewing the Results
Hand it to everyone, not just happy patients
Pick a fixed window, such as every patient for two weeks each quarter, and give the form to all of them. Front desk staff choosing who gets a survey is the fastest way to collect flattering numbers that mean nothing.
Make it anonymous by default
Patients answer more honestly when they do not have to sign. The optional contact line lets someone ask for a call back without forcing everyone to identify themselves.
Close the loop
Tally the results, share them at your staff meeting, and pick one thing to fix. A comment that describes a real problem with care or privacy should go through your patient complaint process rather than sit in a survey pile.
Surveys are not marketing