OUTPATIENT FEEDBACK FORM
Outpatient Feedback Form
Date & Time of Visit
Name of Attending Doctor
Type of Feedback
Compliment
Complaint
First Name
Last Name
Email
Phone
Relationship to patient
Self
Spouse
Parent
Dependent child
Legal guardian
Kindly rate our services
Very poor
Poor
Satisfactory
Good
Very good
Compliment
Please write your compliments here
Complaint
Please check the boxes below which best describe the nature of your complaint.
Substandard Care (e.g. misdiagnosis, negligent treatment, delay in treatment, etc.)
Unprofessional Conduct (breach of privacy, record alteration, provider impairment, etc.)
Office Practice (e.g. inattentive, rude or abusive behaviour, failure to adequately address patients needs, etc.)
Substandard Facilities or Equipment (e.g. cleanliness concerns, cluttered, equipment inoperative, etc.)
Scheduling or Appointment Issues (e.g. difficulty scheduling, not timely, etc.)
Prescribing Issues (e.g. medication errors, over/under prescribing, failure to respond, etc.)
Other
Please write your complaints here
Submit Feedback
