Patient Survey

20%

Name
First Last

Don't worry - we won't contact you regarding this survey or share your info with anyone.
Care Provider

During your visit, your care was provided primarily by the dentist, dental assistant or dental hygienist. Please answer the following questions with that health care provider in mind.
Friendliness / courtesy of the care provider
Explanations the care provider gave you about your problem or condition
Concern the care provider showed for your questions or worries
Care provider's efforts to include you in decisions about your treatment
Information the care provider gave you about medications (if any)
Instructions the care provider gave you about follow-up care (if any)
Degree to which the care provider talked with you using words you could understand
Amount of time the care provider spent with you
Your confidence in this care provider
Likelihood of your recommending this care provider to others
Comments (describe good or bad experience)

Access

Additional questions about your visit: Now that we have asked you to tell us about what happened during your visit, we ask you to rate the services you received.

Instructions: Mark the response that best describes your experience. If a question does not apply to you, please skip to the next question. Space is provided for you to comment on your experiences.
Ease of getting through to the office on the phone
Convenience of our office hours
Ease of scheduling your appointment
Ability of getting an appointment for when you wanted
Courtesy of staff
Comments (describe good or bad experience)

Care Provider