Patient Survey Form

1. Are you a patient completing this survey?

2. How did you find us?

Please give us your feedback using the rating of 1 to 5, with 5 being the highest score

3. When you telephoned to make an appointment, the staff members were courteous and helpful in finding a suitable time?

4. Were you greeted in a friendly manner and made to feel comfortable?

5. The office looks clean with a good appearance and comfort?

6. Were you advised of any delays?

7. Did the Oral Surgeon take the time to listen to your concerns?

8. Did the staff take the time to adequately explain the treatment plan and answer your questions?

9. Would you recommend us to your personal dentist?

10. Did you feel that you understood the prescribed treatment and all of your questions were answered to your satisfaction?

11. If you had a concern during your visit, do you think it was properly handled by the staff?

12. Did you feel that the staff was concerned about your overall well being as a person and not just your dental condition?

13. Using the rating of 1 to 5, with 5 being the highest score how do you rate our office?

14. Overall, did you have a good experience visiting our office?

15. Would you refer a friend or family member to our office?

We are always striving to improve our services. Your comments are important to us. How may we serve you better?