| Patient Survey |
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| Survey Satisfaction ( 5 = highly satisfied, 1 = not satisfied) |
Highly
Satisfied
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Not
Satisfied
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| 1.
Was it easy to schedule a convenient appointment? |
5
4
3
2
1
N/A
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| 2. Were you greeted in a prompt and friendly manner? |
5
4
3
2
1
N/A
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| 3.Was the dentist and/or dental assistant sensitive to your needs? |
5
4
3
2
1
N/A
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| 4. Was your waiting time in the reception area reasonable? |
5
4
3
2
1
N/A
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| 5. Was your treatment explained to your satisfaction? |
5
4
3
2
1
N/A
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| 6. How would you rate the cleanliness of the dental facility? |
5
4
3
2
1
N/A
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| 7. Was your dental treatment completed to your satisfaction? |
5
4
3
2
1
N/A
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| 8. How would you rate your overall experience? |
5
4
3
2
1
N/A
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| Yes/No Answers |
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| 9. Would you return to our dental practice for future treatment? |
Yes
No |
| 10. Would you refer a friend to our dental practice in the future? |
Yes
No |
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Comments:
We welcome your comments to help us improve our business. This information is confidential and will not be made public. |
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| Your Name (optional): |
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