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Patient Referral Experience & Handoff Survey

Tracks how smoothly patients move from being referred to actually being seen by a specialist — scheduling ease, clarity of instructions, and communication between providers — with an AI follow-up that pinpoints exactly where the handoff broke down or worked well. Built for practice managers and care coordination teams.

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Sample questions

A preview of what’s in the template. Every question is editable before you launch.

11 questions · ~6 min
Q01
Message

Thanks for taking a few minutes to share how your recent referral went. Your feedback helps us make handoffs between your provider and specialists smoother for future patients. About 5 minutes.

Q02
Multiple ChoiceRequired

What type of specialist or service were you referred to? (Template note: replace with the specialty list most relevant to your practice.)

  • Cardiology
  • Orthopedics
  • Dermatology
  • Physical Therapy
  • Imaging or Diagnostic Testing
  • Mental or Behavioral Health
  • Other specialist
Q03
Multiple ChoiceRequired

How much time passed between your referral being made and your specialist appointment actually happening (or being scheduled)?

  • Less than 1 week
  • 1-2 weeks
  • 3-4 weeks
  • More than a month
  • I still haven't been able to schedule it
Q04
Opinion ScaleRequired

How clear were the instructions you received about next steps after your referral (e.g., who to call, what forms or authorizations were needed)?

Scale: 1 – 5
Min:Not at all clearMax:Extremely clear
Q05
MatrixRequired

Please rate each part of your referral experience.

4 rows × 5 columns
  • Ease of scheduling the specialist appointment
  • Communication between your primary provider and the specialist's office
  • Amount of information you received about why you were referred
  • Wait time between the referral and your appointment
Columns: Poor · Fair · Good · Very good · Excellent
Q06
Multiple ChoiceRequired

Did you complete the appointment you were referred to?

  • Yes, I completed it
  • Not yet, but it's scheduled
  • No, I decided not to go
  • No, I couldn't get an appointment
Q07
Rating ScaleRequired

Overall, how would you rate your experience with the referral process from start to finish?

Range: 1 – 5
Min:Very poorMax:Excellent
Q08
AI Interview

For respondents whose referral was delayed, incomplete, or rated poorly, reconstruct the specific breakdown: was it the referral paperwork, insurance authorization, scheduling with the specialist's office, or unclear instructions from their own provider. Anchor on the exact point in the process where things went wrong and what would have fixed it. If the referral went smoothly, probe what specifically made the handoff between providers feel seamless so it can be replicated for other patients.

Q09
Opinion Scale

Based on how your referral was handled, how likely are you to recommend this practice to friends or family?

Scale: 0 – 10
Min:Not at all likelyMax:Extremely likely
Q10
Multiple Choice

Which age group do you fall into?

  • Under 18
  • 18-34
  • 35-49
  • 50-64
  • 65 or older
Q11
Message

That's everything — thank you! Your answers will be reviewed by our care coordination team to identify where referral handoffs can be made faster and clearer for future patients.

What’s included

  • AI follow-ups

    Adaptive probes on open-ended answers that pull out detail a static form would miss.

  • Attention checks

    Built-in safeguards against rushed answers and low-quality respondents.

  • AI-drafted copy

    Wording, ordering, and branching written by the AI — tuned to your research goal.

  • Auto report

    Themes, quotes, and a plain-English summary write themselves once responses come in.

How it compares

We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.

Why this template

  • Includes an AI follow-up interview that automatically triggers for respondents whose referral was delayed, incomplete, or rated poorly, and probes to reconstruct exactly where the handoff broke down or worked well — something a static form can't do.
  • Uses a matrix question to rate distinct parts of the referral journey (scheduling, instructions, communication) alongside a separate overall experience rating, so practice managers see both granular and holistic views.
  • Pairs objective process metrics (time between referral and appointment, completion status, clarity of instructions) with recommendation likelihood and demographic segmentation, then rolls it all into an auto-generated report.
  • Opens and closes with conversational chat messages that set expectations and confirm care-coordination staff will review responses, which reads more like a guided conversation than a cold intake form.

Jotform

Patient Referral Form Template

This is a static intake-style form for capturing referral details (e.g., patient info, referring provider, specialist), not a post-referral experience/feedback survey. It's fielding-ready as a document-style form but doesn't measure how the handoff felt to the patient. Jotform's strength is broad customization and integrations rather than experience research.

What it does well

  • Highly customizable drag-and-drop form builder
  • Free tier available
  • Wide range of integrations with EHR/CRM-adjacent tools

Where it falls short

  • No adaptive AI follow-up probing on delayed or poor-quality referrals
  • No automated per-response quality scoring or synthesized report
  • No transparent, publishable prompt/methodology for how responses are analyzed

SurveySparrow

Free Patient Referral Form Template | For Medical Institutions

Framed as a referral intake form for medical institutions rather than a survey tracking the patient's referral-to-appointment experience. Its conversational, chat-like question flow is a genuine strength for completion rates, but it stops at data collection with no deeper diagnostic layer. Free to use, per the page.

What it does well

  • Conversational, chat-style question flow
  • Mobile-friendly design
  • Free template offering

Where it falls short

  • No adaptive AI interview to pinpoint where a handoff broke down
  • No automated quality scoring per response
  • No auto-generated analysis report for care coordination teams

Typeform

Patient Referral Form Template

Another referral-intake-oriented template rather than a purpose-built patient experience/handoff survey. Typeform's polished, one-question-at-a-time interface is a genuine usability strength, but the template is a fixed question set with no dynamic branching into experience diagnostics. Good for basic intake, not for root-cause analysis of referral friction.

What it does well

  • Polished, one-question-at-a-time interface with strong completion UX
  • Easy visual customization
  • Established brand familiarity among respondents

Where it falls short

  • Static question set with no adaptive AI follow-up for poorly-rated referrals
  • No automated per-response quality scoring
  • No voice AI interview option or auto-generated diagnostic report

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