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Form library · GEN-004

Customer feedback

Example template only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. Last reviewed 14 October 2026.

Any business that wants a score and two comments after a visit.

A score from 0 to 10, what went well, and what to change. Name and email are optional, so a person can answer without handing over a file of personal information.

Cross-industry at nopen

Use as is

We add your logo and colours. No setup fee.

Use as is — no setup fee

Minor changes

Tell us what to change. We quote that edit.

Starting point

We build a new form from this brief.

Use as a starting point

nopen

Demo only, no real details

Customer feedback

Example template only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. Last reviewed 14 October 2026.

Fields

  • Score

    0 to 10.

  • What went well

    Free text.

  • What to change

    Free text.

  • Contact

    Optional name and email if they want a reply.

Questions

Is the score a clinical measure?

No. It is a satisfaction score, not a health questionnaire.

Do they have to leave a name?

No. Leave the contact fields blank if you want it anonymous.

About these templates

These templates are examples only, to help you get started. They are general information, not legal, medical, clinical or professional advice, and they may not suit your business, your profession or your state or territory.

Before you use any template, you must review and adapt it, and have it checked where needed, so it fits your services, your professional body's rules, privacy and health records laws, and the law where you operate. This matters most for consent, waiver, privacy and minors' forms. You are responsible for the forms you use and the information you collect.

To the extent the law allows, Nopen gives no warranty that the templates are complete, current or fit for any purpose, and is not liable for loss arising from their use. Nothing here excludes, restricts or modifies any right or remedy you have under the Australian Consumer Law that cannot lawfully be excluded.

The templates are not endorsed by or connected with any government agency, including Services Australia, Medicare or the NDIA. Do not add government logos, the Commonwealth Coat of Arms or other official marks to them. Fields that refer to government numbers (such as a Medicare card number) are labels only.

Templates were last reviewed on 14 October 2026. Laws change, so check that a template is current before you rely on it.

Example template only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. Last reviewed 14 October 2026.

Drafted 14 October 2026.