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Patient Survey Questionnaire
Dear Patients,
We need your input on how we can better serve you. Your feedback on this questionnaire will tell us what you know about our practice. If you decide to include your name while filling out the survey, we will enter you in our monthly draw for a chance to Win a New Oral B Power Brush!


New Patients Welcome

* Optional


  Consistently Sometimes Never
When you telephoned to make an appointment, the staff members was courteous and helpful in finding a suitable time?
Upon arrival, were you greeted in a friendly manner and made to feel comfortable?
Were you seated by your appointment time or advised of any delays?
Did the dentist/hygienist take the time to listen to and understand your concerns?
Did the dentist/hygienist take the time to adequately explain the treatment plan and answer your questions?
Did you feel that you understood the prescribed treatment and all of your questions were answered to your satisfaction?
Upon receiving your bill for the services redeemed was the amount clearly described?
Upon receiving your bill for the services redeemed were payment options discussed?
If you had a concern during your last visit, do you think it was properly handled by the staff?
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?
Are you comfortable with the level of technology used in the office?

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

Suggestions for Improvement:
We are always striving to improve our services. Your comments are important to us. How may we serve you better?


Please use my comments as a testimonial.

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