Patient Survey

First and Last Name: *

Email Address: *

When you telephoned to make an appointment, the staff member was courteous and helpful in finding a suitable time?

YesSomewhatNoNot Applicable

Upon arrival, were you greeted in a friendly manner and made to feel comfortable?

YesSomewhatNoNot Applicable

Were you seated by your appointment time or advised of any delays?

YesSomewhatNoNot Applicable

Did the dentist/hygienist take the time to listen to and understand your concerns?

YesSomewhatNoNot Applicable

Did you feel that you understood the prescribed treatment and all your questions were answered to your satisfaction?

YesSomewhatNoNot Applicable

Upon receiving your bill for the services redeemed was the amount clearly described?

YesSomewhatNoNot Applicable

Upon receiving your bill for the services redeemed were payment options discussed?

YesSomewhatNoNot Applicable

If you had a concern during your last visit, do you think it was properly handled by the staff?

YesSomewhatNoNot Applicable

During your last visit, did you feel that the staff was concerned about your overall well being as a person and not just your dental condition?

YesSomewhatNoNot Applicable

Are you comfortable with the level of technology used in the office?

YesSomewhatNoNot Applicable

How did you hear about us?

Using the rating of 1 to 5, with 5 being the highest score how do you rate our office?

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