214-522-4330

Name:

Phone:

Email:

Comments:




 

Dental Patient Survey

We appreciate you taking the time to complete our survey. Please feel free to comment on your visit as well. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.

*Patient name
*e-mail address
How would you rate your overall visit?
Excellent Very Good Average Not so good
When your appointment was over did you have a good understanding of your dental situation?
Yes Not really I wish I knew more about my situation
Were your financial options explained to you?
Yes No I already understand my financial options
Did you have to wait over 15 minutes past your appointment time to be seated? If so how long?
No 15 to 30 minutes 30 to 45 minutes Over 45 minutes
Did the staff greet you properly?
Yes Not really I don't recall
Would you refer your friends and family to Dr. _______?
Yes No I'm not sure
Please comment on how we could make your visit better, new services you would like to see, or other ways we can make you feel more comfortable. * Required