Patient Questionnaire

We care about the level of service we offer to you. We would be grateful if you would fill out this survey to let us know what you like about our practice, and to also let us know in what areas we need to take action to correct and improve our services to you.

The results of this survey are private and will be kept confidential and used only to improve our level of care to you.

Your opinion is important to us:

Patient Name:
How would you rate your overall visit? Excellent V.Good Average Not so good
Did you receive a friendly greeting from the staff when you entered our practice? Always Usually Occasionally Never
When you call to make an appointment are the staff polite, courteous and helpful? Always Usually Occasionally Never
Were you seated by your appointment time or advised of any delays? Always Usually Occasionally Never
Did the dentist/hygienist and assistants take an adequate amount of time to explain your treatment and answer your questions? Always Usually Occasionally Never
Did you feel that you understood the prescribed treatment and all of your questions were answered to your satisfaction? Yes No Sort of  
How would you rate the professionalism of the staff? Very Professional Average Too Casual Not Professional
If you had a concern during your last visit, do you think it was properly handled by the staff? Yes No    
Using the rating of 1 to 5, with 5 being the highest score how do you rate our office? 1      2      3      4      5     
Suggestions for Improvement:
We are always striving to improve our service to you. Your comments are important to us. Please comment on how we could make your visit better or other ways to make you feel more comfortable.

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