Patient Profile: New Patient Existing Patient
Age: Gender: Travel Distance:
1. What helped you decide to choose our office for your dental care?
Near Home/Work Telephone Listing/Yellow Pages Internet Listing Recommendation of Family/Friends/Other Patients/Associates, etc.. Recommendation by another Dentist/ or Physician/Health Professional
2. Was it easy to get an appointment?
Yes No - What did you find difficult?
Comment:
3. When you called our office, were you treated courteously by our staff?
Yes No - What would you like to share?
4. Upon your arrival, were you seated promptly for your appointment?
Yes, short wait time if any No: minute(s) wait time (fill in time)
6. During your visit, how were you treated by the staff?
Dentist: Yes No Hygienist: Yes No
8. Were you satisfied with the quality of care that you received from your dentist or hygienist?
Comments:
9. Please rate the Dentist/Hygienist on how genuinely interested he/she seemed in your care/condition.
Dentist: Consistently Interested Usually Interested Seemed Indifferent
Hygienist: Consistently Interested Usually Interested Seemed Indifferent
10. Were the fees and billing practices explained to your satisfaction?
Yes No
11. Do you feel the fees are appropriate for the level of dental services rendered?
Yes No Not Sure
12. If a friend were in need of dental services, would you recommend us?
13. What could we do to improve the dental experience you had in our office?