After-Visit Summary Feedback Form

After-Visit Summary Feedback Form — Form Fields

This healthcare template includes 6 fields. Collects patient feedback on the clarity and usefulness of their after-visit summary. Helps care teams improve discharge communication and follow-up instructions. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Visit (text, required)
• Did you receive an after-visit summary? (multiple choice, required) — options: Yes, printed, Yes, via patient portal, No
• How clear were the instructions in your after-visit summary? (rating, required)
• Which section was most helpful? (dropdown selection, optional) — options: Diagnosis and reason for visit, Medications prescribed, Follow-up instructions, Test results, Referrals
• Do you have any suggestions for improving the after-visit summary? (long text, optional)