Urgent Care Clinic Feedback Form

Urgent Care Clinic Feedback Form — Form Fields

This feedback template includes 10 fields. Collect patient feedback on urgent care wait times, provider quality, facility cleanliness, and discharge instructions. Free to customize and use on ZenBuild.

• Your Name (text, optional)
• Email Address (email, optional)
• Reason for Visit (dropdown selection, required) — options: Illness, Injury, Infection, Prescription Refill, X-Ray, Other
• Overall Visit Experience (rating, required)
• Wait Time (rating, required)
• Provider (Doctor/PA/NP) Attentiveness (rating, required)
• Facility Cleanliness (rating, required)
• Were your concerns fully addressed? (multiple choice, required) — options: Completely, Mostly, Partially, No
• Would you return to this clinic? (multiple choice, required) — options: Definitely, Probably, Unsure, Probably Not, Definitely Not
• How can we improve? (long text, optional)