Date :

-- mm/dd/yy

Patients Name (optional):

Name

Did you receive the courteous attention you expected?

Yes No

Was a complete history taken and examination completed?

Yes No

Was the need for treatment adequately explained?

Yes No

Were financial arrangements made to your convenience?

Yes No

Were you kept informed of treatment progress?

Yes No

Were we prompt in rendering treatment each visit?

Yes No

Did we stress oral hygiene education and prevention?

Yes No

Did you or your child feel that you were treated gently?

Yes No

Are you pleased with the results?

Yes No

Did you feel we were interested in you as a person?

Yes No

Did you always reach us when you called?

Yes No

Is our staff respectful and understanding?

Yes No

Is our office neat, clean, pleasant and attractive?

Yes No

Are there any comments you would like to make, or anything else you can suggest that would improve our service or communication? Your compliments, criticism and suggestions are appreciated. Your feedback will assist us in providing better service to all of our patients.