After-Hours Urgent Care Feedback

After-Hours Urgent Care Feedback — Form Fields

This feedback template includes 10 fields. Gather patient feedback on after-hours or urgent care clinic visits covering wait time, treatment quality, and staff care. Free to customize and use on ZenBuild.

• Reason for your visit (dropdown selection, required) — options: Illness, Injury, Infection, Allergic reaction, Follow-up care, Other
• Time of your visit (dropdown selection, required) — options: Weekday evening, Weekend morning, Weekend afternoon, Holiday
• Overall urgent care experience (rating, required)
• Wait time from arrival to being seen (rating, required)
• Medical staff knowledge and attentiveness (rating, required)
• Clarity of diagnosis and discharge instructions (rating, required)
• Was your concern adequately addressed? (multiple choice, required) — options: Yes completely, Yes mostly, Partially, No
• Would you return to this urgent care location? (multiple choice, required) — options: Definitely, Probably, Unsure, Probably not, No
• What could be improved? (checkboxes, optional) — options: Wait time, Bedside manner, Communication, Follow-up instructions, Facility cleanliness, Billing process, Appointment availability
• Additional comments on your visit (long text, optional)