Telehealth No-Show Follow-Up Survey Form

formswrite.com/templates/telehealth-no-show-survey-form

Gathers reasons patients missed a telehealth appointment to reduce future no-shows and improve virtual visit accessibility.

We missed you at your virtual appointment. Please help us understand what happened so we can make things easier.

Patient name *

Your answer

Missed appointment date

Primary reason you missed the visit

Technology issue

Forgot

Schedule conflict

No longer needed care

Privacy concerns at home

Insurance/cost concern

Other

Technology issue details

Did you receive reminder notifications?

Preferred reminder channel going forward

Would you prefer an in-person visit instead?

+ 6 more questions

About this template

Gathers reasons patients missed a telehealth appointment to reduce future no-shows and improve virtual visit accessibility.

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