Patient Information
                                         

Patient Satisfaction Survey

Items marked with an * are required
Date of your visit
*How likely is it that you could recommend us to a friend or colleague?
These are all optional; if it does not apply you may leave it blank.
Communication with our office
Poor
Excellent
Courtesy of Staff                              
Helpfulness of Staff                              
Timeliness in returning your call or email                              
Overall ease in scheduling your appointment                              
Reception in our office
Poor
Excellent
Greeting upon arrival                              
Comfort of Reception Area                              
Waiting time before going to treatment area                              
Reading and educational materials                              
Safeguarding your privacy                              
Treatment in our office
Poor
Excellent
Courtesy of the dental assistant                              
Competence of the dental assistant                              
Courtesy of the dentist                              
Competence of the dentist                              
Courtesy of the hygienist                              
Competence of the hygienist                              
Comfort of the treatment room                              
Concern for your comfort                              
Satisfaction with your treatment                              
Your account with us
Poor
Excellent
Written explanation of your services and fees                              
Processing of your insurance claims                              
Payment options                              
Answering your questions                              
Management of your account                              
Your Overall Experience                              
Comments and Suggestions
P.S. We recognize employees who exceed patient expectations. If anyone provided you with service that you feel deserves special recognition, please provide their name(s).
Your name (optional)
Thank you!