In order that we may better serve your needs, please share your findings concerning your visit with us.
  When you have finished, please press the submit button at the bottom of the screen. We thank you in
  advance for helping us in our commitment to Constant And Never-ending Improvement.

 The services your received

 Please select the services you received in the last 12 months.

  Cleaning
  Periodontal Care
  Extractions		 Emergency Care
Restoration
Cosmetic		 Dentures
Implants
Braces

 Background questions

 Date of Visit: Time of Visit:

Was this the first time you have used our practice?

Yes No

Did you see the dentist on every visit?

 Yes No

Did someone review your medical history?

 Yes No

Are you covered by dental insurance?

 Yes No

Were you informed about the type of services we offer

 Yes No

Were you in any discomfort during your treatment?

 Yes No

 Main source of payment: Self-Pay Private Insurance Preferred Provider

 Miscellaneous                 
 

Very Poor

Poor

Fair

Good

Very Good

 Comfort of  the greeting area

 Cleanliness of facility

 Equipment / Facility modern & up-to-date

 Front desk staff concern for your needs

 Assisting staff attention to your needs

 Hygienist attentive to your needs

 Doctor attentive to your needs

 Options for treatment clearly explained

 A vailability of payment options

 Likelihood of recommending us to others

 Overall rating of care provided

 Length of time between calling for an
 appointment and being seen

 Helpfulness of the person scheduling
 your appointment

 Convenience of hours

 Appointment timeliness

 Teamwork shown by dental team

 Thoroughness of exam and treatment

 Friendliness of the dental assistant

 Professionalism of the dental assist

 Professionalism of the Hygienist     

 Education provided by the Hygienist
 on oral hygiene

 Comments