Satisfaction Survey

Was this your first visit to our office or have you been here before? 1st Visit Repeat patient
Who did you see?
What was the purpose of your visit?
On a scale of 1 to 5, with 5 being "Great," how would you rate your experience on your last visit? If a particular line does not apply to your visit, please skip it.
 PoorFairOkayGoodGreat
Ease of setting your appointment:
Greeting by our receptionist when you arrived:
Cleanliness/neatness of the waiting room:
Cleanliness/neatness of the operatory:
Length of time you had to wait before you were called for your appointment:
Friendliness of our office staff:
Friendliness of the dentist:
Quality of the service performed:
Degree to which your concerns were addressed by either the technician or the dentist:
The ease of checking out and paying after the appointment:
How likely is it that you would recommend our dental office to your family members, co-workers, and friends?
In your own words, let us know any issues or concerns you may have about our services or office practices and procedures.
If you would like to provide us with your contact information, please use the boxes below:
Name:
Phone Number:
Email Address:
Security test. Please identify the pictures: