This printable pharmacy patient satisfaction survey helps community and retail pharmacies collect honest feedback from every customer at the counter, including those who never open an email or app. The form prints on two pages, uses 12 questions, and takes about four minutes to complete.
What this survey measures
The survey focuses on the parts of the pharmacy visit that shape satisfaction and loyalty. A rating grid captures how customers feel about waiting time for prescriptions, the friendliness and helpfulness of the staff, the clarity of advice, the availability of the products they need, privacy when discussing their health, cleanliness, and value for money. A medicines section checks whether prescriptions were ready and whether patients understand what their medicines are for and who to contact with a problem. Customers also tell you which services they would use, such as vaccinations or home delivery, and how they want to hear that a prescription is ready. A recommend question gives you a simple loyalty signal to track over time, and an open comment box captures anything the fixed questions miss.
How to use it on paper
Hand the survey to customers when they pick up a prescription, or leave copies at the counter with a drop box nearby. Customers fill the checkboxes with a blue or black pen. Collect the completed forms and scan them in batches: PaperSurvey reads the checkbox answers with optical mark recognition and converts the handwritten comments to text automatically, so results appear in your dashboard without any manual data entry.
Customize this template
Add your pharmacy logo, reword the rating statements to match your services, or add questions about specific counters like the vaccination clinic or consultation room. The paper layout reflows automatically as you edit, and every copy you print stays scannable.
Preview the PDF above, or use this template to start collecting pharmacy feedback today.