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Dentist Name:

What dental work did you have done while at our office:
CleaningFillingsCrownsBridge UnitsVeneersDenturesOther

HOW WOULD YOU RATE THE FOLLOWING:

Speed of your call being answered: Very GoodGoodFairPoor

Ease of finding our office: Very GoodGoodFairPoor

Helpfulness of receptionist: Very GoodGoodFairPoor

Waiting room facilities: Very GoodGoodFairPoor

Timekeeping (were you kept waiting long?): Very GoodGoodFairPoor

Welcome received from dentist: Very GoodGoodFairPoor

Explanation of your treatment: Very GoodGoodFairPoor

Helpfulness of dental assistant: Very GoodGoodFairPoor

Professionalism of staff and approach: Very GoodGoodFairPoor

Information provided about payment: Very GoodGoodFairPoor

Overall satisfaction with the service provided: Very GoodGoodFairPoor

Would you recommend us to your family and friends? YesNo (If no, please explain why?)

Additional Comments / Suggestions:

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First Name:

Last Name:

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Thank you for taking the time to complete this questionnaire.