Patient Satisfaction Survey

Thank you in advance for taking time to give us feedback on your experience in this dental office. Your input will assist us in improving our services and care to you, our valued patient. We ensure your responses are totally confidential. We will know "what" is said, but not "who" said it.

The quality of my dentist's efforts to reduce my anxiety:

Please rate each of these statements on a scale of 1 to 10 (1=Failing, 10=Excellent)

The quality of treatment I received:

Level of respect and courtesy I receive:

Amount of time my dentist spends with me:

Amount of time I wait in the reception area to see the dentist or hygienist:

How long I needed to wait to get in for another appointment:

Explanation of financial arrangements for treatment:

Precautions taken to prevent transmission of disease:

Pleasantness of the dental office:

Cleanliness of the dental office:

Competence of the dental staff:

Politeness of the receptionist:

Friendliness of the office staff and assistants:

Evaluate the degree to which you feel care at this office is worth the cost:

I would recommend this dental office to a relative or friend:

I am satisfied with the care that I received from this dental office:

Availability of the dentist if I have a dental emergency:

Answer only if applicable

Speed in processing my dental insurance claims:

Answer only if applicable

Attention paid to billing concerns:

Answer only if applicable

The quality of the specialists to whom I've been referred:

Answer only if applicable

What is your zip code?:

How long have you been a patient in this practice?:

How were you referred to this practice?:

What one thing would you like to see improved at this dental office?:

Any final comments or suggestions?:

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Patient Satisfaction Survey