Please help us improve our service by taking this short survey about your dental visit. Any comments will be kept strictly confidential. We will review all feedback. We appreciate you taking the time to help us serve you better!

Patient Name (Optional)

Email Address (Optional)

How would you rate your overall visit?
Please Choose One Excellent Very Good Average Not So Good

What makes you rate it this way?

What was the best part of your experience at our practice?

How could we make your experience better, or improve our service for your next visit?

Hygienist
Please Select One I Don't Remember Anne Cathy Lori

Dental Assistant
Please Select One I Don't Remember Amy Lorna Maggie Maureen

When your appointment was over did you have a clear understanding of your dental situation?
Please Select One Yes Not Really I wish I knew more about my situation

Were your financial options explained to you?
Please Choose One Yes No I already understood my financial options

Did you have to wait past your appointment time to be seated? If so, how long?
Please Choose One No wait, I was seated at or before my appointment time Less than 15 minutes 15 to 30 minutes 31 to 45 minutes More than 45 minutes

Would you refer your friends of family to us?
Please Choose One Yes No

If yes, why? If no, why not?

Please comment on how we could make your visit better, new services you would like to see, or other ways we can improve our service or make you feel more comfortable.