Dentists4Kids.com - Survey Form

Patient Survey Form

Patient Name
(Optional)
How would you rate your overall visit?		Very Satisfied
		Satisfied
		Somewhat Satisfied

Did the staff treat you professionally on the phone?		Yes
Did the staff treat you professionally on the phone?		No
		I do not recall

Did the staff greet you properly?		Yes
		No
Comments

Were the assistants and hygienist's friendly and professional to you and your child?		Yes
		No
Comments

Was the doctor professional and courteous to you and your child?		Yes
		No
Comments

Did cleanliness of our practice meet your expectations?		Yes
Did cleanliness of our practice meet your expectations?		No

Were your financial matters handled in a timely and well addressed manner?		Yes
		No

Would you refer your friends and family to us?		Yes
Would you refer your friends and family to us?		No

Please comment on how we could make your visit better...
Please type "123" in the box at right to validate your submission.