Patient Name (Optional):

How would you rate your overall visit?
Very Satisfied
Satisfied
Somewhat Satisfied

How satisfied were you with the staff on the phone?
Very Satisfied
Satisfied
Somewhat Satisfied

Did the staff greet you properly?
Yes
No

Comments

Were the assistants and hygienist's friendly and professional to you and your child?
Yes
No

Comments

Was the doctor professional and courteous to you and your child?
Yes
No

Comments

Did the cleanliness of our practice meet your expecations?
Yes
No

Were your financial matters handled in a timely and well addressed manner?
Yes
No

Would you refer your friends and family to us?
Yes
No

Please comment on how we could make your visit better...