1. How would you rate your overall visit?

Excellent Very Good Average Not so good

2. Did you receive a friendly greeting from the staff when you entered our office?

Always Usually Occasionally Rarely Never

3. When you call to make your appointment, is the staff polite, courteous and helpful?

Always Usually Occasionally Rarely Never

4. Did the dentist and assistants take an adequate amount of time to explain your treatment and answer your questions?

Always Usually Occasionally Rarely Never

5. When you visit our office, how long do you usually have to wait (after your scheduled appointment time) before you are seated in the dental chair?

Little or no time 1-10 minutes 11-20 minutes 21+minutes

6. How would you rate the professionalism of the staff?

Very professional Average Too Casual Not Professional

7. Were your financial options explained to you?

Yes No I already understand my financial options

8. Would you refer your friends and family to us?

Yes No Not Sure

9. Please comment on how we could make your visit better or other ways to make you feel more comfortable.

10. Please provide with your name and email address.

*Name:

*Email: