Post-Appointment Survey

We appreciate your business and want you to be satisfied with every aspect of your treatment. Realizing that we do so much with our mouth (speaking, smiling, eating, etc.), we recognize that our success in serving you can be a significant factor in your overall satisfaction in life.

Our highest priority, every day, is to provide our patients with consistently superior service. If we have failed to serve you properly in any way or simply have not measured up to your expectations, we would like to know.

This questionnaire is intended to help us evaluate our performance, especially in cases where we might have fallen short for some reason. Please take a moment at your convenience to rate our effort.

Thank you for giving us the opportunity to serve you.

Please tell us about your appointment:

Bold fields are required.

Initial Visit
Introduction to Office
Interview
Doctor's Exam
Financial Discussions
Questions Answered
Reception Areas
Telephone Calls
Staff Hospitality
Areas Neat and Clean
Insurance Handling
Special Requests
Treatment Areas
Care and Empathy
Courtesy and Response
Helpfulness
Competence/Knowledge
Cleanliness
General Comments
Professionalism
Personal Comforts
Office Atmosphere
Would you recommend our service to others?


 
Contact Information:

Would you like a member of our team to contact you to further discuss your experience?

Please provide your name and email address:

 
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