patient satisfaction survey

Please take a moment to complete our survey. Your comments are welcome and completely confidential. Your input will help us improve our service. Thank you.

We appreciate you taking the time to complete our survey. Please feel free to comment on your visit as well. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.
 

Patient Name :
E-mail Address :
Date of your last visit:
How was the treatment you received :	------------------------------- Select ------------------------------- Excellent Very Good Average Poor
How comfortable were you during the treatment you received :	------------------------------- Select ------------------------------- Very Not so comfortable Uncomfortable
Was your treatment explained to you so that you have a clear understanding of your dental situation :	------------------------------- Select ------------------------------- Yes No
Were your financial options explained to you? :	------------------------------- Select ------------------------------- Yes No I already understand my financial options
How long did you wait before being seated in a room?	------------------------------- Select ------------------------------- 0 minutes/no wait 15 30 45 Longer
Would you refer your friends and family to us? :	------------------------------- Select ------------------------------- Yes No Maybe
Please comment below on how we could make your next visit better and more comfortable. Thank you :