1) On a scale of 1-10, 10 being highest, how satisfied are you with the care you received on your most recent visit?12345678910
2) What was the nature of your visit? New Patient Cleaning Emergency Visit Fillings/Crown Extractions/Implants/Surgery Other
3) Were you seated on time? Yes No
4) If you had to wait, how long were you waiting? (If not applicable, jump to question 5)
5) Please rate your satisfaction on a scale of 1 to 10 with 10 being highly satisfied. Not applicable is also a choice.
Ease of scheduling an appointment12345678910
Friendliness of the staff and Doctor12345678910
Explanation of treatment and financial obligationsNot applicable12345678910
Cleanliness of office12345678910
Sensitivity to needs12345678910
6) How would you rate your hygienist in the following categories on a scale from 1 to 10 with 10 being highly satisfied?
Quality of Teeth Cleaning12345678910
General hygiene knowledge and ability to answer questions12345678910
7) Would you like to try a different hygienist? Yes No
(If yes, please email the office with your name and number and we will be happy to schedule you with someone new. We have four different hygienists each with their own unique style. We believe we have a hygienist that will be right for you!)
Rate the next four questions only if you received anesthesia and had a procedure performed during your visit. If not, skip to question 13.
8) What type of procedure(s) were performed? Filling Crown Root canal Extraction Dental Implant IV Sedation Other
9) On a scale of 1-10 with 10 being the most comfortable, how would you rate your experience in receving the anesthetic injection?12345678910
10) Were you satisfied with how numb you were throughout the procedure? Yes No
11) On a scale of 1-10, how satisfied are you with the finished result of your procedure?
12) What could we have done to make this visit a better experience?
13) Would you refer a friend to our practice in the future? Yes No
Thank you for taking the time to complete this survey. Your feedback will enable us to improve our patient care and make your future visits as positive as possible.