--- title: "Patient satisfaction survey template: 10 questions to copy" description: "A patient satisfaction survey template: 10 questions, 2-3 minutes, no health data. With an intro, questions by specialty and how to collect Google reviews too." url: https://repto.pl/en/blog/patient-satisfaction-survey-template updated: 2026-11-11 language: en --- # Patient satisfaction survey template (and how to collect Google reviews alongside it) A ready-to-copy patient satisfaction survey (10 questions, 2-3 minutes, no health questions) with an intro, extra questions by specialty and a simple way to turn happy patients into Google reviews. ![Piotr Czupryński](https://images.ctfassets.net/a0z5tmqqa31s/6SGfiXsVk1fIobEEmU6G4R/3430d8b606532144278a0ec4fe7c25e1/ja_profile_compressed.jpg) Piotr Czupryński November 11, 2026 14 min read ![Patient satisfaction survey template (and how to collect Google reviews alongside it)](https://images.ctfassets.net/a0z5tmqqa31s/7MwwP4zV8Vvk5QyiV1F6Hs/bb328b83d5012bb4c910988722e6d88d/hero.en.png) A patient satisfaction survey is a short, anonymous questionnaire in which patients rate their visit: booking, reception, punctuality, the conversation with the doctor and the clinic itself. A good one has **up to 10 questions**, takes 2-3 minutes to fill in and asks nothing about the patient's health. There's a ready-to-copy template below. The survey tells the clinic what patients think, but future patients **will never see the results**. That's why, at the end, I show how to collect [Google reviews](https://repto.pl/en/blog/google-reviews-for-medical-practices) alongside the survey. ## Does a medical practice have to run a patient satisfaction survey? That depends on the country and on who pays for the visits. A private clinic usually doesn't have to, but **it definitely should**. The survey shows what bothers patients before they write about it on Google, and better service means more referrals, more good reviews and, in the end, more patients. Because a dental practice, a dermatology clinic or an aesthetic medicine clinic runs the survey for its own use, **it can cut it down to a few questions**. Clinics funded by a public payer may have to survey patients as part of a quality system. In Poland, for example, clinics with a contract with the national health fund (NFZ) must survey patients anonymously under a 2023 law on healthcare quality and patient safety, and the Ministry of Health publishes ready-made templates for it (more on them below). ## Patient satisfaction survey template (ready to copy) The template has 10 questions and takes a patient 2-3 minutes. The questions follow the order of the visit, from booking to leaving the consulting room, and wherever the patient gives a rating, **the scale is 0-10** throughout. There are no questions about diagnosis, treatment, age or sex, so **patients can fill it in anonymously**. ### Survey intro "Thank you for visiting \[clinic name\]. This survey is anonymous and takes 2-3 minutes. Please don't include any information about your health or any personal details." ### Questions 1. 1. How did you book this appointment? - By phone / at reception / on the clinic's website / through a booking portal / other. 2. 2. How easy was it to get an appointment at a time that suited you? - Scale 0-10, where 0 = very difficult, 10 = very easy. 3. 3. How would you rate the service at reception? - Scale 0-10, where 0 = very poor, 10 = very good. 4. 4. Did your appointment start on time? - Yes / up to 15 minutes late / more than 15 minutes late. 5. 5. Did the doctor give you enough attention? - Scale 0-10, where 0 = definitely not, 10 = definitely yes. 6. 6. After the visit, do you know what happens next (advice, medication, further tests)? - Yes / partly / no. 7. 7. Did you know the cost of the visit beforehand? - Yes / no / not applicable (visit covered by insurance or public funding). 8. 8. How would you rate the cleanliness of the clinic? - Scale 0-10, where 0 = very poor, 10 = very good. 9. 9. How likely are you to recommend our clinic to family or friends? - Scale 0-10, where 0 = not at all likely, 10 = extremely likely. 10. 10. One thing we should change: - Free-text field, optional. Below the field: "Please don't describe your health." Before sending or printing it, the clinic can add two fields that the patient doesn't fill in: - **Location**, if you have several sites, because each has its own reception and its own Google Business Profile. - **Type of visit: first or follow-up**, because a new patient sees the clinic differently from a regular one. Question 1 is more useful than it looks: it shows how many patients book by phone and how many through your website or a booking portal. Question 9 is the NPS question. How to calculate the score from it is in my post on [NPS in healthcare](https://repto.pl/en/blog/nps-in-healthcare-how-to-calculate). The template leaves out age and sex on purpose. Official templates may include them (Poland's Ministry of Health has them in its own), but in a small clinic **age, sex and the day of the visit are enough to work out who filled in the survey**, and then it's no longer anonymous. ## What do official patient survey templates look like? As an example, Poland's Ministry of Health publishes 7 survey templates as PDFs: primary care for adults, primary care for children, home visits, phone consultations, specialist outpatient care, hospital stays and long-term care. The primary care and specialist templates each fit on one A4 page. How to organize phone and video consultations so patients don't spend the whole day waiting by the phone is covered in my post on [telemedicine consultations](https://repto.pl/en/blog/telemedicine-consultations-patient-reviews). The adult primary care survey has **14 questions** and one 0-10 scale for every rating. It asks how the patient booked, how easy booking was, about reception, punctuality, the doctor's engagement, access to tests, prevention, how clear the information was, cleanliness, the waiting room and respect for patients' rights, and at the end about recommending the clinic (NPS), age and sex. Below the questions there's a box for comments. The specialist care survey has 12 questions in the same layout. A clinic that has to run an official survey can use the official template as it is. A private clinic can borrow questions from one, but I'd start with the shorter template above and take from the official one only what's missing, for example **a question about access to tests**. ## What should you write at the start of the survey? Four things: **what you're thanking the patient for, how long it takes, that the survey is anonymous**, and a request not to describe their health. The intro in the template above works for an online survey. Versions for other channels: - **Paper survey:** "Thank you for your visit. This survey is anonymous and takes 2-3 minutes. Please drop the completed survey into the box at reception." - **SMS with a link:** "Thank you for visiting \[name\]. Please rate your visit in a short, anonymous survey (2-3 minutes): \[link\]" ## How do you write questions patients will actually finish? Keep it short, because every extra question gives the patient another reason to close the survey halfway through. The less effort a survey takes, **the more patients finish it**, and few patients will get to the end of a long hospital-style survey after a routine appointment. The template above follows these rules: - **One question, one topic.** "How would you rate reception and the waiting time?" is really two questions in one, and the patient will answer whichever one annoyed them more. - **One scale for every rating.** If 10 means "very good" in question 3, it can't mean "very poor" in question 8. A 0-10 scale has another advantage: the NPS question uses the same one. - **Ask about a specific visit.** Patients answer a question about "today's visit" more precisely than one about "our clinic in general". - **Keep the free-text field optional.** Anyone who has something to say will write it anyway. ## Which questions should you add for each specialty? Add one, at most two, questions that fit the specialty and leave the rest of the template as it is. Examples: - **Dentistry:** "Before treatment, were you given a treatment plan with the costs?" - **Diagnostics and laboratories:** "Was your result ready by the date reception gave you?" and "Did you know how to prepare for the test?" - **Aesthetic medicine:** "Was the expected result discussed before the treatment?" Send this survey only after 2-4 weeks, when the result is visible. - **Dermatology:** "Did the doctor look at all the spots or skin concerns you wanted to show them?" - **A child's visit:** a parent fills in the survey, so the visit questions are about the child ("Did the doctor give your child enough attention?"), and one extra question reads: "Did the doctor also talk to your child?" - **Phone consultation:** "Did the doctor call at the agreed time?" instead of question 4, and the question about cleanliness goes. ## Paper, online or SMS: what works in a clinic? **A survey handed to the patient in person gets the most responses**, and one the patient has to find online on their own gets the fewest. There's little data on how many clinic patients answer surveys, but a [review of more than 2,500 survey studies in surgery](https://research.rug.nl/en/publications/global-overview-of-response-rates-in-patient-and-health-care-prof/) (Meyer et al., Annals of Surgery, 2022) shows a clear order: response rates of about 76% for in-person surveys, 65% for postal and 46% for online ones. Those studies count patients and doctors together, so treat the numbers as a direction. In an ordinary outpatient clinic you're unlikely to see 76%. The channel also affects the ratings themselves. A patient filling in the survey in the waiting room rates differently than at home, so **I wouldn't compare results from different channels**. ### Paper survey The upside: no equipment or software, just printed surveys, a pen and a box at reception. The downsides: someone has to type the answers into a spreadsheet, only patients who had a moment after the visit respond, and anonymity at the front desk, under the receptionist's eye, is mostly theoretical. And if someone opens the box once a quarter, you'll hear about a problem at reception **three months later**. ### Online survey: link, QR code, tablet, email The tool counts the results for you, and you can follow them as they come in, separately for each location. The problem is the same as with QR codes for reviews: **someone has to point the patient to the survey**, otherwise the poster with the code just decorates the waiting room. I've seen a clinic where the review QR code on the front desk ended up exactly like that, because nobody asked patients to scan it. How to set up a [Google review link and QR code](https://repto.pl/en/blog/google-review-link-qr-code-generator) that patients actually use is covered in a separate post. ### SMS survey An SMS with a link reaches patients from the visit list without reception having to do anything, and the best time to send it is **the day after the visit**, while the patient still remembers it well. In [a clinic group that collects Google reviews with Repto](https://repto.pl/en/blog/clinic-group-1766-new-google-reviews), 17% of patients opened the link in the SMS and 90.9% of them rated their visit. The link there led to a single question, so fewer people will finish a 10-question survey. ## Is a patient satisfaction survey GDPR-compliant? It can be, as long as it **doesn't collect more data than it needs**. The template above doesn't ask for a name, ID number, age, sex, diagnosis or treatment, and below the free-text field it asks patients not to describe their health. A few things remain the clinic's job: - Sending the survey by SMS requires the patient's phone number and a legal basis for contacting them, which the clinic should confirm with its data protection officer. - The survey **stops being anonymous** once you add a field like "leave your number and we'll call you back". That field can be useful, but it then needs a privacy notice next to it. - A survey tool processes data on the clinic's behalf, so you need a data processing agreement with the provider. - Read free-text answers with medical confidentiality in mind. If a patient describes their treatment despite the request, that part shouldn't end up in a presentation for the board. ## How do you analyze patient satisfaction survey results? Once a month, separately for each location and each question. An average across the whole survey says little, because **a poor rating for reception gets lost** in the average when the doctors score high. - Look for the question with **the lowest rating**. If punctuality keeps getting the weakest scores, you know where to start. - Read every comment. In a small clinic that's a dozen or so sentences a month, and they'll tell you more than a chart. - Compare the same channel over time. A tablet survey and an SMS survey are two different measures. - Decide who calls the patient back, and at what rating. For example, if a patient left their contact details and gave a 0-4 on any question, **the manager calls the next day**. A call like that often settles the matter before the patient writes about it online. And if a review has already appeared on Google, you'll find sample replies that don't break medical confidentiality in my post on [responding to negative patient reviews](https://repto.pl/en/blog/respond-to-negative-patient-reviews). I compare surveys, NPS and Google reviews as three different measures of satisfaction in my guide on [how to measure patient satisfaction](https://repto.pl/en/blog/measure-patient-satisfaction-csat-nps). ## How can you collect Google reviews alongside the survey? Ask the patient for a Google review **at the same moment** they rate the visit. The survey shows that patients are happy, but nobody sees that on Google, because nobody asked them for a review. Clinics even tell me: "the only reviews we get organically are negative ones", even though most patients leave satisfied. The survey alone won't change that. We checked 653 public Google profiles of medical facilities in Kraków, Poland (as of 20 October 2026): primary care clinics with a national health fund (NFZ) contract, which have to survey patients under that contract, average **3.45★ on Google, while private clinics average 4.51★**. Many things affect that gap, waiting lists for a start, but the survey these clinics run anyway does nothing for them on Google: the results stay in a drawer, and the reviews come mostly from patients who want to complain. [MultiClinic](https://repto.pl/en/blog/clinic-from-166-to-1446-google-reviews) is a good example too: 2,500 reviews on a Polish doctor booking portal with a 5.0 average, and 166 reviews on Google with a 3.7 average. They're the same patients, but **the booking portal asks for a review after the visit**, and Google doesn't. What you can do with the survey you already have: 1. 1. Add your Google review link to the thank-you page. The patient has just finished the survey and has their phone in hand, so one sentence, "We'd be grateful for a Google review of your visit", costs you about as much as copying a link. 2. 2. Give a patient who rated the visit poorly the clinic's contact details too. That way they talk to the manager first and only then decide what to write online. 3. 3. Don't send the survey and the review request as separate SMS messages on the same day. Two messages after one visit is one too many. 4. 4. **Split the two jobs.** I wouldn't send 10 questions after every visit. Send the full survey once a quarter or to a share of patients, and after each visit, a single 1-5 rating (like Google's stars) plus a review request is enough. Ready-made wording for these requests, by SMS and on paper, is in my [review request templates](https://repto.pl/en/blog/google-review-request-sms-templates). You can send the requests by hand, or, if you'd rather not deal with it, [Repto](https://repto.pl/en) sends them automatically the day after the visit and can collect an NPS score at the same time. A patient who rates the visit poorly reaches the clinic first: they can describe what went wrong, and the manager gets an email and can call them back. It's a safety net, and the clinic can switch it off. ## FAQ ### What is a patient satisfaction survey? A short, anonymous questionnaire in which patients rate their visit: booking, reception, punctuality, the doctor and the clinic itself. It tells the clinic **what to improve** before patients write about it online. ### How many questions should a patient satisfaction survey have? **Up to 10 questions, 2-3 minutes**. Even fewer for a survey sent after every visit: one question for an overall rating and an optional comment. ### Does a patient satisfaction survey have to be anonymous? Surveys that a public payer requires are often anonymous (in Poland, the one for NFZ-funded clinics is). A private clinic decides for itself, but **patients answer more honestly when they're anonymous**, so make any contact field optional. ### Where can I find a patient satisfaction survey template? There's one to copy earlier in this post. Public health bodies sometimes publish their own: Poland's Ministry of Health, for example, offers 7 templates, including ones for primary care, specialist care, phone consultations and hospitals. ### How often should you survey patient satisfaction? A short rating after every visit, and **the full survey once a quarter**. Review the results every month, separately for each location. ### Can a survey replace Google reviews? **No.** Nobody outside the clinic sees the survey results. A patient looking for a doctor sees the number of reviews and the average rating on Google. If you have questions about collecting Google reviews, [book a short call with us](https://repto.pl/en/contact). ![Piotr Czupryński](https://images.ctfassets.net/a0z5tmqqa31s/6SGfiXsVk1fIobEEmU6G4R/3430d8b606532144278a0ec4fe7c25e1/ja_profile_compressed.jpg) About the author Piotr Czupryński · CEO Założyciel i twórca Repto, zarządza stroną techniczną produktu i skutecznością zbierania opinii ## Related articles ![Google review response templates for clinics (that keep patient confidentiality)](https://images.ctfassets.net/a0z5tmqqa31s/9LN9FMwHOsLmEEQERkt2Y/eb931c21068a02250ee2eb7946192918/hero.en.png) ### [Google review response templates for clinics (that keep patient confidentiality)](https://repto.pl/en/blog/google-review-response-templates-clinics) ![MultiClinic grew its Google reviews from 166 to 1,446 in under 11 months](https://images.ctfassets.net/a0z5tmqqa31s/2onl19hYm1rWoZgrP8hxR1/f1d1f46ea3e396dc7bf5cf45493a50b4/hero.en.png) ### [MultiClinic grew its Google reviews from 166 to 1,446 in under 11 months](https://repto.pl/en/blog/clinic-from-166-to-1446-google-reviews) ## 15 minutes to see if it's worth it It's a short online call, in English. I'll look at your Google reviews and show you the dashboard. Then I'll work out the cost and a forecast: how many reviews you could collect from your visit volume at a typical conversion rate. ![Piotr Czupryński](https://repto.pl/main_page/me.jpg) Piotr Czupryński Founder of Repto or [Email kontakt@repto.pl](mailto:kontakt@repto.pl)