1. Was this your first visit to our office?

First Visit Repeat Patient (Skip to #3)

2. If you answered First Visit, how did you hear about us?

Referred by another patientBNI referralInternet searchYellow Page AdRadio SpotTelevision FeatureMagazine FeatureOther (Please Specify)

Other

3. What was the purpose of your visit?

Cleaning, exam, x-raysRestoriative DentistryEmergency DentistryCosmetic DentistryConsultationSpa Services

On a scale of 1 to 5, with 5 being "Great," how would you rate your experience on your last visit? If a particular line does not apply to your visit, please skip it.

4. Ease of setting your appointment

Poor Fair Okay Good Great

5. Greeting by our receptionist when you arrived

Poor Fair Okay Good Great

6. Cleanliness/neatness of the waiting room

Poor Fair Okay Good Great

7. Cleanliness/neatness of the operatory

Poor Fair Okay Good Great

8. Length of time you had to wait before you were called for your appointment

Poor Fair Okay Good Great

9. Friendliness of our office staff

Poor Fair Okay Good Great

10. Friendliness of the dentist

Poor Fair Okay Good Great

11. Quality of the service performed

Poor Fair Okay Good Great

12. Degree to which your concerns were addressed by either the technician or the dentist

Poor Fair Okay Good Great

13. The ease of checking out and paying after the appointment

Poor Fair Okay Good Great

14. In your own words, let us know any issues or concerns you may have about our services or office practices and procedures.

15. How likely is it that you would recommend our dental office to your family members, co-workers, and friends?

Poor Fair Okay Good Great

If you would like to provide us with your contact information please use the boxes below:

16. Name:

17. Phone Number:

18. Email Address: