1. Please rate the following aspects of your appointment:
Ease of making an appointment
[ Select One ] Very Poor Poor Fair Good Excellent
Length of wait to get an appointment
[ Select One ] Very Poor Poor Fair Good Excellent
Ample and convenient parking
[ Select One ] Very Poor Poor Fair Good Excellent
Length of time you waited to see your provider
[ Select One ] Very Poor Poor Fair Good Excellent
Cleanliness and appearance of office
[ Select One ] Very Poor Poor Fair Good Excellent
Comfort of waiting area
[ Select One ] Very Poor Poor Fair Good Excellent
Comfort of exam rooms
[ Select One ] Very Poor Poor Fair Good Excellent
2. Please rate our office staff in these areas:
Courtesy of office staff
[ Select One ] Very Poor Poor Fair Good Excellent
Respectful handling of confidential information
[ Select One ] Very Poor Poor Fair Good Excellent
Promptness in answering the phone
[ Select One ] Very Poor Poor Fair Good Excellent
Clearly answering questions
[ Select One ] Very Poor Poor Fair Good Excellent
3. Please rate the provider you saw for your appointment in these areas:
Conducted a thorough exam
[ Select One ] Very Poor Poor Fair Good Excellent
Showed concern and sensitivity to my needs
[ Select One ] Very Poor Poor Fair Good Excellent
Answered my questions about my dental health
[ Select One ] Very Poor Poor Fair Good Excellent
Gave me a chance to make decisions about my care and treatment
[ Select One ] Very Poor Poor Fair Good Excellent
Explained treatment options in a way I could understand
[ Select One ] Very Poor Poor Fair Good Excellent
Gave me the right amount of attention and time
[ Select One ] Very Poor Poor Fair Good Excellent
Clearly explained what any prescriptions were and how to use/take them
[ Select One ] Very Poor Poor Fair Good Excellent
An estimate of future treatment expense was given to me
[ Select One ] Very Poor Poor Fair Good Excellent
Overall, would you recommend this office to others?
Yes, definitely recommend Maybe I would recommend No, would not recommend
Tell us one (or more) thing(s) that we could have done to make your visit better:
Do you have something you'd like to speak with us about?
No Yes
If you answered "Yes", please complete the following:
Name:
Street:
Town: Zip:
Phone: E-Mail
