This telehealth patient satisfaction survey helps clinics and virtual care teams gather structured feedback on every video and phone visit, using 8 questions across one printable page. It captures how patients experienced the technology, the provider, and the value of care delivered remotely.
What this survey measures
The rating grid covers the essentials of a good virtual visit: whether the technology was easy to use, whether patients could see and hear their provider clearly, whether the provider listened and addressed concerns, whether the needed care was delivered, whether the visit saved time, and whether the patient would use telehealth again. A follow-up question asks how the visit compared to an in-person appointment, and an open comment box invites specific 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.