Patient Survey

Patient Satisfaction Survey

In order to find out how we are meeting your needs, we are asking our patients a few questions about the care they have received. Please be honest in your answers. Your comments will be held in strict confidence and you do not have to sign your name unless you want to. We plan to use your suggestions to make our service to you and your family even better. Thank you for your comments.

Please complete items 1 – 4 to describe yourself:

1) Age  18-25 26-40 41-55 over 55
2) Gender  male female
3) The number of visits I have made to the office in the past year is:  1 2 3 4 5 or more
4)  My Treatment                                     or  My Childs treatment was
     completed  not completed

The list below includes statements about the care you received at our office.

Please place a check mark under the column to indicate whether you agree, disagree or are not sure about each one. Please explain the ones you disagree with next to "Comments."

Appointments

Agree Unsure Disagree
  • It was easy to make my first appointment.
 Agree  Unsure  Disagree
  • The appointment secretary (coordinator) was polite and helpful.
 Agree  Unsure  Disagree
  • I received a reminder of each of my appointments.
 Agree  Unsure  Disagree
  • It was easy to schedule a convenient appointment.
 Agree  Unsure  Disagree
  • Appointment options were given that suited my schedule.
 Agree  Unsure  Disagree
  • I was seen on time for my appointments; if not, I was given a reason for the delay.
 Agree  Unsure  Disagree

Comments

Facilities

Agree Unsure Disagree
  • The office location and parking were convenient.
 Agree  Unsure  Disagree
  • The reception area was neat and clean.
 Agree  Unsure  Disagree
  • The equipment was clean and presentable.
 Agree  Unsure  Disagree
  • The temperature in the office was comfortable.
 Agree  Unsure  Disagree
  • The lighting in the office was sufficient.
 Agree  Unsure  Disagree
  • The music in the office was pleasant.
 Agree  Unsure  Disagree

Comments

Patient Satisfaction Survey (continued)

Staff

Agree Unsure Disagree
  • The dentist was professional and courteous.
 Agree  Unsure  Disagree
  • The dental hygienist was professional and courteous.
 Agree  Unsure  Disagree
  • The dental assistant was professional and courteous.
 Agree  Unsure  Disagree
  • The dentist was considerate and sensitive to my needs.
 Agree  Unsure  Disagree
  • The dental hygientist was considerate and sensitive to my needs..
 Agree  Unsure  Disagree
  • The dental assistant was considerate and sensitive to my needs.
 Agree  Unsure  Disagree
  • Other office personnel were courteous and helpful.
 Agree  Unsure  Disagree

Comments

Treatment

Agree Unsure Disagree
  • My proposed dental treatment was clearly explained.
 Agree  Unsure  Disagree
  • Any questions I had were answered.
 Agree  Unsure  Disagree
  • I was given treatment alternatives
 Agree  Unsure  Disagree
  • My dental treatment was completed efficiently and in a timely manner.
 Agree  Unsure  Disagree
  • I was pleased with the quality of my dental treatment.
 Agree  Unsure  Disagree
  • The dental treatment was completed to my satisfaction.
 Agree  Unsure  Disagree
  • The fees were explained prior to my treatment appointment.
 Agree  Unsure  Disagree
  • The fees for service were fair.
 Agree  Unsure  Disagree
  • I plan to remain a patient at this office.
 Agree  Unsure  Disagree

Comments

Additional Comments

What I liked best about the office was:

What I liked least about the office was:

In what way(s) could we have made your experience better?

Name (optional)

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