Dental Patient Survey

*Patient name

*E-mail address

*Date of Appointment

Did we make you feel welcome and serve you in a friendly manner?
Yes No

Did you have to wait over 15 minutes past your appointment time to be seated? If so how long?
No 15 to 30 minutes 30 to 45 minutes Over 45 minutes

Were all procedures discussed with you prior to your appointment?
Yes No

Did we provide a comfortable understanding of the financial options available to you?
Yes No

Were you offered the use of any of our spa amenities?
Yes No

Would you refer our office to a friend and family member?
Yes No I'm not sure

Please provide us with any additional comments you may have:

* Required