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
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
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
No
     
Please comment on how we could make your visit better...

Please type "123" in the box at right to validate your submission.

 

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