Patient Survey

Name

Email Address

Date/Time of Appointment

1. Overall, how would you rate your visit?

2. Upon completion of your appointment did you have a good understanding of your dental situation?

3. Were your financial options explained to you?

4. Did you have to wait past your appointment time to be seated? If so, how long?

5. Did our team greet you properly?

6. Would you refer your friends and family to us?

7. Please comment on anyone within our team, things we could change, new services you would like to see, or any other ways we can make you more comfortable for future visits.