Patient Survey

We care about the level of service we offer to you, and hope your visits with us are always pleasant. In order for us to continue to serve our patients with excellent customer service, we would appreciate it very much if you could provide us with your assessment of your most recent experience by answering our brief anonymous Patient Survey.

New Patient Visit                    Emergency Visit                      Hygiene Visit                            Treatment Visit

Outstanding                             Very Good                                Good                                           Poor

Yes | No

Very difficult

Outstanding

Discourteous

Very courteous

Yes | No| N/A

0 to 5 minutes

10 to 15 minutes

20 to 40 minutes

Other

 

Unfriendly

Very Friendly

 Yes | No

 

The Doctor

 Yes |  No |  N/A

 Attentive                                                       Concerned                                                    Friendly

Distracted                                                      Rushed                                                           Insensitive

 Outstanding                                                  Good                                                               Adequate

 Needs improvement                                 Poor                                                                 N/A

Yes |  No |  N/A

 Outstanding                                                  Good                                                               Adequate

Needs improvement                                Poor                                                                 N/A

The Hygienist

Outstanding                                                  Good                                                               Adequate

Needs improvement                                 Poor                                                                  N/A

Outstanding                                                  Good                                                               Adequate

Needs improvement                                Poor                                                                  N/A

 

Additional Feedback

 0-1 year                  1-5 years                5-10 years                  10-20 years                  20+ years

 Yes | No

  Yes | No

 

Personal Information

 

 

 

 

 

 

 

 

 



 

 

 

 Yes | No

Thank you for taking the time to fill out our survey. We rely on your feedback to help us improve our services. Your input is greatly appreciated.