Patient Feedback Form
A patient feedback form helps a clinic or hospital understand the patient experience. This free template rates the care, the staff and the waiting time, and invites comments, so healthcare teams can improve service. It is for experience feedback only, not medical advice or records.
check_circleFree, unlimited responses, no login for respondents
What is inside this template
Ready-made questions you can keep, edit or remove.
Who uses the patient feedback form
How to use this template
From template to live form in four steps.
Click Use This Template to load it straight into your free SurveyHeart account.
Change the wording, add or remove fields and set what is required. No design work needed.
Send it by WhatsApp, email or QR code. Respondents fill it on any device, no app or login.
See answers in real time and export to Excel, CSV and PDF whenever you want.
Related templates
A patient feedback form lets a clinic measure the experience around a visit, from waiting time to staff manner to cleanliness. Kept simple and anonymous, it encourages honest answers that point to real improvements. SurveyHeart shows the ratings as charts and keeps comments for context, and exports cleanly for admin review. The form is free and needs no login. It collects experience feedback only and is not for medical records or advice.
Frequently asked questions
No. It is for experience feedback only. Do not use it to collect diagnoses or medical records.
Yes. Leave out the name field so patients can answer freely.
Yes, the template and unlimited responses are free.
Use the Patient Feedback Form now
Free plan, unlimited responses, no time limit.