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Patient Survey
Patient Name
Email
Date of your last visit
How was the treatment you received
-- Select --
Excellent
Very Good
Average
Poor
How comfortable were you during the treatment you received
-- Select --
Very
Not so comfortable
Uncomfortable
Was your treatment explained to you so that you have a clear understanding of your dental situation
-- Select --
Yes
No
Were your financial options explained to you?
-- Select --
Yes
No I already understand my financial options
How long did you wait before being seated in a room?
-- Select --
0 minutes/no wait
15
30
45
Longer
Would you refer your friends and family to us?
-- Select --
Yes
No
Maybe
Please comment below on how we could make your next visit better and more comfortable. Thank you.
