Free Feedback Form Template
Designed with care workflows in mind, this healthcare form template helps you collect patient and feedback information securely. It is built around measurable feedback so you can spot trends and act on them.
What is a feedback form?
A feedback form is an online form that lets you collect healthcare-related information from respondents in a structured, consistent way. It suits clinics, therapists, and care providers gathering intake, consent, and satisfaction data.
Fields to include in your feedback form
- Full name
- Email address
- Phone number
- Overall rating (1–5 stars)
- Satisfaction score
- What went well
- What could be improved
- Open comments
How it works
- 1
Generate with AI
Click "Generate with AI" and ZenForms instantly builds a complete form tailored to this template — fields, labels, and structure included.
- 2
Edit and customize
Tweak fields, add your own questions, set required items, and match your brand in the drag-and-drop builder.
- 3
Publish and share
Publish your form and share the link. Responses land in your dashboard, ready to review and export.
Common use cases
- Collecting patient intake details
- Gathering appointment and booking requests
- Running patient satisfaction and feedback surveys
- Recording treatment consents
Frequently asked questions
What is a feedback form?
A feedback form is an online form that lets you collect healthcare-related information from respondents in a structured, consistent way. It suits clinics, therapists, and care providers gathering intake, consent, and satisfaction data.
How do I create a feedback form?
Click "Generate with AI" on this page and ZenForms builds a complete feedback form for you in seconds. You can then edit the fields and design in the drag-and-drop builder before publishing.
How do I collect useful feedback with this form?
Use a mix of rating scales for quick, quantifiable scores and open comment fields for context. Rating fields make it easy to spot trends, while comment fields capture the "why" behind the numbers.
Is this form HIPAA compliant?
ZenForms is not a certified HIPAA-compliant platform. Avoid collecting protected health information, and use this template for non-sensitive intake, feedback, and general requests only.
What should a patient intake form include?
Typically contact details, the reason for the visit, and any relevant preferences. Keep sensitive medical data out of online forms unless you have a compliant system in place.
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