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Patient Information

Survey Form

Our practice is committed to delivering the best quality dental care available. Because we are fully committed to excellent customer service, we value your opinion on ways we can improve. Please take a moment to share your feedback with us. You may leave this questionnaire with one of our staff members, or you may email it to our office. Thank you for having confidence in our practice.

Expectations Expectations
-were courteous
on the phone		 -offered a comfortable
clean office setting
-scheduled appointment
within a reasonable
amount of time		 -delivered prompt service
-gave you a friendly
greeting upon arrival		 -was professional and
efficient
-looked professional
in appearance		 -staff was attentive and
compassionate, both
before and after surgery
-thoroughly explained the
financial arrangements		 -Dr. and team made you
feel comfortable and
provided quality dentistry
-Dr. and team worked
well together		 -How would you rate our
overall performance?

WE WOULD LIKE TO KNOW MORE ABOUT YOU:

What is your relationship to this office?

What was the date of your visit?

Would you recommend our office to others?

Did any one individual provide you with excellent service?
Name:
Why?

What did you like most about our office?

What areas do you feel we could make some improvements?