| 1. Your Name |
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| 2. Your e-mail address |
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| 3. When you last called our office, was the staff polite, courteous, and helpful? |
Definitely
Mostly
Somewhat
No
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| (other comments - was that a typical experience with us?) |
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| 4. At your last visit, when you entered our office, were you greeted in a friendly and welcoming manner? |
Definitely
Mostly
Somewhat
No
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| (other comments - was that a typical experience with us?) |
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| 5. At your last visit, did the dentist, hygienist, or assistant take adequate time to explain your treatment needs, ensure you understand, and answer your questions? |
Definitely
Mostly
Somewhat
No
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| (other comments - was this typical of your previous visits with us?) |
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| 6. At your last visit, how long did you wait in the reception area (after the scheduled time of your appointment) before you are seated in the dental chair? |
Little or no time
5-10 minutes
11-15 minutes
16-20 minutes
21+ minutes
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| (other comments - was this wait typical of your previous visits with us?) |
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| 7. At your last visit, how satisfied were you with service you received from the dentist? |
Definitely
Mostly
Somewhat
Not satisfied
Didn't see the dentist at last appointment
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| (why? and was this typical of your previous experiences with us?) |
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| 8. At your last visit, how satisfied were you with service you received from the hygienist? |
Definitely
Mostly
Somewhat
Not satisfied
Didn't see the hygienist at last appointment
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| (why? and was this typical of your previous experiences with us?) |
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| 9. At your last visit, how satisfied were you with service you received from the chair-side assistant? |
Definitely
Mostly
Somewhat
Not satisfied
Didn't see the assistant at last appointment
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| (why? and was this typical of your previous experiences with us?) |
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| 10. At your last visit, how satisfied were you with service you received from the receptionist/front office staff? |
Definitely
Mostly
Somewhat
Not satisfied
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| (why? and was this typical of your previous experiences with us?) |
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| 11. At your last visit, were you satisfied with the way you are treated as an individual and as a patient in our dental office? |
Definitely
Mostly
Somewhat
No
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| (why? and was this typical of your previous experiences with us?)) |
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| 12. How likely are you to continue to receive your dental care with us? |
Definitely
Most Likely
Maybe
Probably Not
Definitely Not
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| (why?) |
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| 13. If you had a friend or family member that needed a dentist, would you recommend us to them? |
Definitely
Most Likely
Maybe
Probably Not
Definitely Not
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| (why?) |
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| 14. Did you know you can earn rewards by sending us new patients? |
Yes
No
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| 15. What can we do to make your visits & experiences with us more pleasant and enjoyable? |
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| 16. If you experienced our new in-House, Same-Day Crown Technology, What did u think? |
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| 17. Overall, how would rate your experience with us? (5-Stars is highest rating) |
5-Stars (Excellent)
4-Stars (Very Good)
3-Stars (Good)
2-Stars (Fair)
1-Stars (Poor)
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