| 1. Your Name |
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| 2. Your e-mail address |
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| 3. When you called our office, was the staff polite, courteous, and helpful? |
Definitely
Mostly
Somewhat
No
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| (other comments) |
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| 4. Was making your 1st appointment easy and pleasant? |
Definitely
Mostly
Somewhat
No
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| (other comments) |
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| 5. Prior to your visit, did the staff: - offer you directions to our office or - offer to provide you the new-patient forms or - get your insurance information? |
Definitely
Mostly
Somewhat
No
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| (other comments) |
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| 6. When you arrived at our office, were you greeted in a friendly and welcoming manner? |
Definitely
Mostly
Somewhat
No
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| (other comments) |
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| 7. How long did you wait in the reception area (after the scheduled time of your appointment) were you 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) |
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| 8. How would you rate the professionalism (e.g. personable, caring, informative, knowledgeable, skilled) of the chair-side assistant? |
Very Professional
Average
Below Average
Not Professional
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| (other comments) |
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| 9. How would you rate the professionalism (e.g. personable, caring, informative, knowledgeable, skilled) of the dentist? |
Very Professional
Average
Below Average
Not Professional
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| (other comments) |
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| 10. How would you rate the professionalism (e.g. personable, caring, informative, knowledgeable, skilled) of the hygienist? |
Very Professional
Average
Below Average
Not Professional
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| (other comments) |
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| 11. How would you rate the professionalism (e.g. personable, caring, informative, knowledgeable, skilled) of the receptionist/front office staff? |
Very Professional
Average
Below Average
Not Professional
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| (other comments) |
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| 12. 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) |
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| 13. If your treatment needs were complex, were you offered a follow-up Treatment Consult/Review Appointment? |
Yes, I was offered one.
No, I was not offered one, but wish I had been offered one.
No, I did not need a follow-up treatment review appointment.
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| (other comments) |
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| 14. Were you satisfied with the service you received and the way you were treated both as an individulal and as a patient? |
Definitely
Mostly
Somewhat
No
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| (other comments) |
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| 15. How likely are you to continue to recieve your dental care with us? |
Definitely
Most Likely
Maybe
Probably not
Definitely not
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| (why?) |
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| 16. 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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| 17. Did you know you can earn rewards by sending us new patients? |
Yes
No
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| 18. What can we do to make your visits & experiences with us more pleasant and enjoyable? |
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| 19. Overall, how would rate your experience with us? (5-Stars is highest rating) |
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