Please take a moment to tell us about your experience.

 
When you called our office, was your call handled promptly and courteously?

very satisfied
satisfied
neither satisfied nor dissatisfied
dissatisfied
very dissatisfied

 
Where you able to get a appointment Day and Time that was satisfactory to you?

Yes
No

 
Did you have any problem finding the office?

Yes
No

 
When you arrived, how long did you have to wait until being seen by the doctor?

0 to 10 minutes
10 to 20 minutes
20 to 30 minutes
30 to 45 minutes
45 or more minutes

 
How Would you rate the following?

 
The courtesy of the receptionists.

Excellent
Above Average
Average
Below Average
Poor

 
The courtesy of the assistants.

Excellent
Above Average
Average
Below Average
Poor

 
The professional appearance of the staff.

Excellent
Above Average
Average
Below Average
Poor

 
Your impression of the appearance and cleanliness of our office.

Excellent
Above Average
Average
Below Average
Poor

 
The surgeon's patience and interest in your treatment

Excellent
Above Average
Average
Below Average
Poor

 
The surgeon's explanation of your treatment plan.

Excellent
Above Average
Average
Below Average
Poor

 
The assistant's explanation of your post-operative care.

Excellent
Above Average
Average
Below Average
Poor

 
Our explanation of your charges, payment and insurance responsibilities.

Excellent
Above Average
Average
Below Average
Poor

 
Would you refer patients to our office in the future?

Yes
No

 
Would you recommend your dentist continues to refer patients to our office?

Yes
No

 
Do you know anyone who you would refer to our office or someone we could contact that would benefit from our care?

Name:
Phone Number:

 
Additional comments: