Patient Survey

Your Opinion is important to us!

We thank you for choosing our practice as your oral health care provider. As you know, our practice is committed to 100% patient satisfaction. We believe that excellent patient care and superior customer service go hand-in-hand. As a practice dedicated to exceeding patient expectations, we value your opinion. To help us accurately gauge the level of customer service provided in our practice we ask that you complete this patient survey.

Our People...
were courteous on the phone.
Exceeded   Met   Below   N/A  
gave you a friendly greeting upon arrival.
Exceeded   Met   Below   N/A  
were helpful.
Exceeded   Met   Below   N/A  
provided thorough explanations on your progress during and after treatment.
Exceeded   Met   Below   N/A  
looked professional in appearance.
Exceeded   Met   Below   N/A  
Overall, how did our staff perform?
Exceeded   Met   Below   N/A  

Quality Care and Service...
How well did our staff provide you with quality service in these areas?
reception area and front desk.
Exceeded   Met   Below   N/A  
explanation of financial arrangements.
Exceeded   Met   Below   N/A  
care by doctor.
Exceeded   Met   Below   N/A  
Overall, how would you rate our care and service?
Exceeded   Met   Below   N/A  

Our Office...
scheduled an appointment for you within a reasonable amount of time.
Exceeded   Met   Below   N/A  
delivered prompt service by the doctor.
Exceeded   Met   Below   N/A  
offered a comfortable, clean reception area.
Exceeded   Met   Below   N/A  
Overall, how would you rate the office efficiency?
Exceeded   Met   Below   N/A  

We would like to know more about you...
What is the gender of the patient?
Male   Female  
What is your relationship to this office?
Patient   Parent of Patient   Adult Child of Patient  
What is the age group of the patient?
Under 18   18-35   36-55   Over 55  
How long have you been coming to our office?
1st visit   Less than 3 mos   3-12 mos   1-5 yrs   More than 5 yrs  
Would you recommend our office to others?
Definitely Would   Definitely Would Not   Uncertain  

Thank You!

 

Optional
We welcome your comments regarding your general impression of our people and office. Please comment below.
Did anyone provide you with outstanding service?
Yes   No  
Name(s):  
I am especially pleased with:  
You need to improve:  
If you have additional comments and would like to be contacted by a member of our staff, please write your name and telephone number in the space provided.
Name:  
Phone Number: