Which of the following influenced your decision to make an appointment with us?
 Proximity to home or office
 Availability to make an appointment (timeliness)
 Referral from another patient
 Referral from a friend, employee or family member
 Physician scheduled appointment
 Affordable Care
 Found it online

Name of the patient

Name of the Doctor


Contact Number

Please rate our services

Ability to get a timely appointment
 Poor Good Very Good Excellent

Clinical Success
 Poor Good Very Good Excellent

Courtesy and Helpfulness
 Poor Good Very Good Excellent

Doctor Interaction
 Poor Good Very Good Excellent

Ambience of the Dental Clinic
 Poor Good Very Good Excellent

Explanation of Treatment
 Poor Good Very Good Excellent

Overall experience
 Poor Good Very Good Excellent

How long did you have to wait for the appointment?
 15 mins 30 mins 1 hour

Are you likely to refer our services to others?  Yes No

Do you want to stay in touch with us for your dental care concerns online?  Yes No

Do you have any comments/ suggestions to help us improve our services?

How was your experience? Do you wish to compliment us?

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