Missed appointment survey template
Why the patient missed the appointment and what would help them attend next time, to reduce no-shows.
4 questions · about 1 minute to complete · free on every plan
Free account required. The template is copied into your workspace; edit anything before publishing.
- When to use it
- The day after a missed appointment.
- Who it is for
- Patients who did not attend.
How to use this template
- Send it within 48 hours of the visit; response rates and recall both fall the longer you wait.
- Ask about communication ('explained things in a way I understood') before overall satisfaction.
- Do not ask for diagnoses or medications in a general feedback survey.
Questions in the missed appointment survey template
1. What was the main reason you could not attend?
single choice · Forgot, Could not get time off, Transport, Felt better, Did not receive a reminder, Childcare or caring duties, Cost, Other
2. How would you like reminders?
single choice · Text message, Email, Phone call, App notification
3. Would an earlier, later or video appointment have helped?
single choice · Earlier in the day, Later in the day, Weekend, Video appointment, None of these
4. Anything else that would help you attend?
open text
What the results look like
IllustrativeSynthetic sample of 120 responses generated for this preview, not real survey data. Your results page shows the same charts for your own responses.
1.What was the main reason you could not attend?
120 answered| Answer | Count | Percent |
|---|---|---|
| Forgot | 7 | 6% |
| Could not get time off | 23 | 19% |
| Transport | 7 | 6% |
| Felt better | 4 | 3% |
| Did not receive a reminder | 25 | 21% |
| Childcare or caring duties | 15 | 13% |
| Cost | 10 | 8% |
| Other | 29 | 24% |
2.How would you like reminders?
120 answered| Answer | Count | Percent |
|---|---|---|
| Text message | 14 | 12% |
| 23 | 19% | |
| Phone call | 39 | 33% |
| App notification | 44 | 37% |
3.Would an earlier, later or video appointment have helped?
120 answered| Answer | Count | Percent |
|---|---|---|
| Earlier in the day | 25 | 21% |
| Later in the day | 15 | 13% |
| Weekend | 19 | 16% |
| Video appointment | 18 | 15% |
| None of these | 43 | 36% |
How to read these questions
- single choice: Read the share choosing each option, then cross-tab by a segment question to see who differs.
Frequently asked questions
Does a patient satisfaction survey need HIPAA safeguards?
If it collects no health information and is anonymous, generally no. If you link responses to patient records or ask about conditions, treat it as protected health information and get advice.
How long does the missed appointment survey take to complete?
About 1 minute: 4 questions, most of them single-tap. Every question can be edited, removed or reordered in the builder before you publish.
Is this template free to use?
Yes. Every template is included on the Free plan. Sign up, click Use this template, and it is copied into your workspace where you can edit it, add your logo and share it by link, email or embed.
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