This telehealth patient satisfaction survey helps clinics and virtual care teams gather structured feedback on every video and phone visit, using 14 questions across two printable pages. It captures how patients experienced the technology, the provider, and the value of care delivered remotely.
What this survey measures
An agreement grid covers the essentials of a good virtual visit: whether patients could see and hear their provider clearly, whether the provider listened, explained things and addressed concerns, whether the needed care was delivered, and whether the visit saved time. A second grid rates scheduling, joining instructions, audio and video quality, waiting time, privacy, and follow-up, and a short question records any technical problems. Follow-up questions ask how the visit compared to an in-person appointment and which the patient would prefer next time, a recommendation rating captures overall advocacy, a short about you section records age group, confidence with technology and any help joining, and two comment boxes invite specific praise and suggestions the fixed questions may miss.
How to use it on paper
Hand this survey to patients at the end of an in-clinic follow-up, or mail it with post-visit paperwork for patients who prefer paper over a portal link. Patients fill the checkboxes with a blue or black pen and add comments in the space provided. 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 manual data entry.
Customize this template
Add your practice logo, reword the statements to match your service lines, or add questions about specific platforms and appointment types. Remove any rows that do not apply, and the paper layout reflows automatically so every printed copy stays scannable.
Preview the PDF above, or use this template to start collecting telehealth feedback today.