1. What did you like most about our office?


2. What did you like least about our office?


3. Did you find our website useful and informative?
Yes No

If no, please explain


4. Upon arrival were you greeted courteously?
Yes No

If no, please explain


5. Were you seated in a timely manner?
Yes No

If no, please explain


6. Did you feel the doctor and team listened and understood your dental concerns?
Yes No

If no, please explain


7. Was the information and explanation of your dental condition and treatment options made clear?
Yes No

If no, please explain


8. Were financial obligations discussed and financial arrangements made to your satisfaction?
Yes No

If no, please explain


9. Were you pleased with the dental treatment that your child received?
Yes No

If no, please explain


10. Was the reception area, restroom and treatment room clean and comfortable?
Yes No

If no, please explain


11. Would you recommend us to others?
Yes No

If no, please explain


12. How far would you be willing to drive to come to our office?
5 minutes or less 10 minutes or less 20 minutes or less greater than 30 minutes

13. Are there any team members you would like to recognize for outstanding care or servce?


14. Please comment on any other aspects of your visit:


Your Name (OPTIONAL):


Email Address: