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Specialist referral survey template

Shorten the road to a specialist, and send the notes along with it

Three questions for after the specialist appointment: how long patients waited for it, whether the specialist already had their information and how clear the next steps were. Use it as it is or change any question, and Usertick reads every response for urgency and customer risk.

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What this specialist referral survey tells you

A specialist referral survey follows the patient from the referring practice to the specialist: how long they waited for the appointment, whether their information arrived before they did and whether they knew what came next. This template asks three questions in about 25 seconds.

It is written for after the specialist appointment, sent by Usertick email from the referring practice or the specialist's office to the patients seen that week. The same survey runs as a link in your own follow-up emails or as a QR code at the specialist's front desk.

Results shows the share of each waiting band, the share whose specialist already had their information and the average clarity of next steps with the share of 4s and 5s. Each response gets an urgency and a customer risk reading, so a referral that went wrong is easy to find in the inbox.

In an emailAs a linkOn your websiteAs a conversation
Questions
3
Time to answer
Under a minute
Written for
After the specialist appointment, by email from either office
Plans
Every plan, the free plan included

See it on every channel

The same template on your website, behind a link, in an email and as a conversation.

In an email

Send it from Usertick to a contact list, with the first question inside the email. A tap on an answer opens the rest of the survey with that answer already kept. Usertick sends 50 emails a month on the free plan, or connect your own sender.

The 3 questions, one by one

What each question asks, why it is there, what it shows you and what to change.

Question 1 of 3 · Multiple choice

How long did you wait for your specialist appointment?

Why ask it
The wait between the referral and the appointment is the part patients feel most, and it is spread across both offices. Bands from less than a week to more than three months match how people remember it.
What you learn
A donut with the share and count of each band, and the stacked shares over time, so a growing share of 1 to 3 months shows a backlog building.
Make it yours
When you refer to several clinics, add a question that names the clinic, then select each answer to compare the waits.
Question 2 of 3 · Yes / No

Did the specialist already have your information?

Why ask it
A specialist without the referral notes has to ask again what the patient already told the first office, and the patient notices. A yes or no shows whether the information traveled.
What you learn
The share that said yes, against the period before. Select No to see how those patients rated the clarity of their next steps.
Make it yours
When the share is low, check how referrals are sent between the two offices, then watch the share in the next period.
Question 3 of 3 · Stars

How clear were your next steps after the referral?

Why ask it
After a specialist visit, the next steps often involve both offices, such as a follow-up, an appointment elsewhere or a return to the referring doctor. A 5-point rating from very unclear to very clear shows whether anyone explained them.
What you learn
The average, a bar per rating and the share who rated 4 or 5, compared with the period before.
Make it yours
Add an optional text question after it, such as What would have made the referral easier?, and Usertick files each answer under a category such as booking and appointments.

What the answers show

Results turns each question into numbers you can follow week by week.

How clear were your next steps after the referral?

The average rating and the share who gave 4 or 5 stars, against the period before.

How long did you wait for your specialist appointment?

The share of each answer with its count. Select an answer to narrow the whole page to those people and read what else they said.

Use this template in four steps

From the template to the first answers.

  1. 1

    Open the template

    Sign up free and pick Specialist referral in the template gallery. It opens in a matching style, ready to change.

  2. 2

    Make the questions yours

    Reword any question, change the options, and add logic or more questions.

  3. 3

    Choose where it runs

    Show it on your website, send it by email, share its link and QR code, or switch it to a conversation.

  4. 4

    Publish and read the answers

    Answers arrive in Results and the inbox as people send them, each written one read and filed by Usertick.

Tips for this survey

Small choices that keep people answering and the answers useful.

  1. 01

    Agree on who sends it

    Decide whether the referring practice or the specialist's office sends the survey, so each patient gets it once.

  2. 02

    Send it after the appointment

    Send in the days after the specialist visit, once patients know the next steps. Usertick doesn't send on its own when an appointment is checked out, so schedule the send.

  3. 03

    Share results with partner offices

    From Pro, a scheduled PDF report sends a dashboard with the waiting bands and the share who arrived with their information to the offices you work with most.

  4. 04

    Keep the reason for referral out

    Ask about the wait, the information and the next steps, never why the patient was referred. Usertick's terms don't allow medical details in surveys, and Usertick doesn't sign business associate agreements.

Customer effort scorePatient satisfaction surveysEmail surveysReferrals and specialists questions

More customer effort templates and questions

Templates like this one, and single questions from the library to add to it.

Templates

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Customer effortLab testMeasure the lab experience from booking to results, including waits at the lab. Send it once results are released.
Customer effortVaccination clinicLearn how easy it was to get an appointment, how long people waited and whether aftercare information was clear. Send it the day after the appointment.

Questions from the library

Browse the question library
  1. How easy was it to get your referral moving?Customer effort · Referrals and specialists
  2. How many days passed before the specialist contacted you?Ruler · Referrals and specialists
  3. Did you know who to chase while you waited?Yes / No · Referrals and specialists
  4. How easy was it to book a time?Customer effort · Booking and appointments
  5. How did you make the booking?Multiple choice · Booking and appointments
  6. Was a time that suits you available?Yes / No · Booking and appointments

Frequently asked questions

A few days after the specialist appointment, when the patient knows the next steps. Usertick sends email now or at a time you schedule up to 30 days ahead.

Either can. The referring practice sees how its referrals land, and the specialist sees how its intake works. Agree on one sender, so patients get the survey once.

Three is enough for a quick check. This template takes about 25 seconds, so patients can answer on a phone between other things.

Select No to narrow Results to those patients, then trace how their referrals were sent. Fix first the route that loses information most often.

No. Usertick's terms don't allow health records or medical details in surveys and Usertick doesn't sign business associate agreements, so the questions stay on the wait, the information and the next steps.

Yes. Every template comes with every plan, the free plan included, and the free plan covers 150 responses a month across your surveys.

Yes. The template becomes your own survey, so reword any question, add or remove questions, and change the options and the logic. The gallery stays as it is.

Yes, from Starter. The template is written in US English. Add languages by hand or with AI translation, and each person sees the survey in their browser's language.

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