Patient Survey

In order for our office to better service your dental needs, please kindly share with us your feelings and experiences concerning your most recent visit by filling out this survey. When you have completed it, please press the submit button at the bottom of the form. Thank you in advance for your assistance.

Background Questions

Please indicate all of the services that you received within the last 12 months.

Are You Please Specify
	A New Patient *	An Existing Patient *

What Services have we performed
Cleaning	Restoration	Extractions
Periodontal Care	Cosmetic	Emergency Care
Consultation	Veneers	Dentures

Please indicate your answers to the following based on your last visit with us.

Your Contact Information (Optional)
First Name: Optional	Last Name: Optional
Email:	Phone:
Best: Time To Contact:	Time?:
Visit Date:	Visit Time:

Was This Your First Time Visit to Our Practice?	Yes	No
Did Someone Review Your Medical History?	Yes	No
Did Someone Discuss With You the Various
Types of Services That We Offer Our Patients?	Yes	No
Are You Currently Covered by Dental Insurance?	Yes	No

Opinion Questions

Please Indicate Your Overall Experience With Our Office and Staff.

Office & Staff
	Very				Very
	Good	Good	Fair	Poor	Poor
Comfort of the Lobby/Waiting Area:
Cleanliness of Facilities:
Convenience of Office Hours:
Convenient Parking:

Front Desk Staff’s Attentiveness to Your Needs:
Assisting Staff’s Attentiveness to Your Needs:
Hygienist’s Attentiveness to Your Needs:
Doctor’s Attentiveness to Your Needs:

Clear Explanation of Treatment Options:
Availability of Payment Options:
Helpfulness of the Staff in
Scheduling Your Appointment:
Length Between Calling For An
Appointment & Being Examined:
Teamwork Exhibited By Our Dental Team:
Thoroughness of Exam & Treatment:
Friendliness of Dental Assistants:
Professionalism of the Dental Assistants:
Professionalism of the Hygienist:
Oral Hygiene Education Provided by the Hygienist:
Overall Rating of Care Provided:
Likelihood of Recommending Our Practice To Others:

Overall Rating of the Web Page:

Additional Comments

Please provide any additional feedback regarding our office and staff.