Patient Survey
Patient Name (optional)
E-mail Address (optional)
Who were you here to visit today?
How would you rate your overall visit?
Was it easy for you to make an appointment?
When your appointment was over did you have a good understanding of your dental situation?
Were your financial options explained to you?
Did you have to wait past your appointment time to be seated? If so how long?
Was the reception area welcoming?
Did the staff greet you properly?
Were you treated professionally during your visit?
Would you refer your friends and family to us?
How did you find out about us?
Please comment on anyone you ment during your visit, things we could change, new services you would like to see, or other ways we can make you feel more comfortable?
Dr. Matthes
Hygienist
Excellent
Very good
Average
Not so good
Yes
No
I don't recall
Yes
No
I wish I knew more about my situation
Yes
No
I already understood my financial options
No
15-30 minutes
30-45 minutes
over 45 minutes
Yes
No
I don't recall
Yes
No
I don't recall
Yes
No
I am not sure
Yes
No
I am not sure
Friend/Family
Website
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Other