We want to hear from you!
Please let us know how we're doing and how we can improve our services.

All information will be kept confidential. We will not share your information with any outside parties. * are required fields.

Name*

Email*

Email*
(retype)

#1.

Please rate the following:
(1 =Best, 5 =Worst)

1
2
3
4
5
N/A

Receptionist

Billing Coordinator

Hygienist

Dental Assistant

Doctor

#2.

Who provided your dental serrvices?

#3.

Was the time and date of your appointment convenient for you?

YES NO

#4.

Was the office neat and clean?

YES NO

#5.

Were you seen within 10 minutes of your scheduled appointment time?

YES NO

#6.

If you experienced a delay, were you informed why there was a delay?

YES NO

#7.

Was the recommended treatment plan explained to your satisfaction?

YES NO

#8.

Did you feel that you received quality care?

YES NO

#9.

Were your needs and expectations:

EXCEEDED MET NOT MET

#10.

Did our staff show concern for you?

YES NO

#11.

Were you comfortable?

YES NO

#12.

If you were uncomfortable, did the person treating you make it better?

YES NO WAS NOT UNCOMFORTABLE

Additional Comments:





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