Emergency Department Feedback Form

Emergency Department Feedback Form — Form Fields

This healthcare template includes 6 fields. Collect patient feedback on their experience in the emergency department. Captures wait time satisfaction, communication clarity, and pain management. Supports ED quality improvement and patient satisfaction goals. Free to customize and use on ZenBuild.

• Time of Visit (dropdown selection, required) — options: Morning (6 AM – 12 PM), Afternoon (12 PM – 6 PM), Evening (6 PM – 12 AM), Overnight (12 AM – 6 AM)
• Overall satisfaction with your ED experience (rating, required)
• How well was your pain managed? (rating, required)
• How was the wait time to see a provider? (multiple choice, required) — options: Acceptable for my condition, Longer than expected but reasonable, Too long
• Were discharge instructions clearly explained? (multiple choice, required) — options: Yes – very clearly, Somewhat – I had questions, No – not explained
• Additional comments (long text, optional)