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 understood 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   No   I don't recall

Would you refer your friends and family to us?
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.