Patient Name:
How would you rate your overall visit? Very Satisfied Satisfied Somewhat Satisfied
Did the staff treat you professionally on the phone? Yes No I don't recall
Did the staff great you properly? Yes No Comments
Were the assistants and hygienist's friendly and professional to you and your child? Yes No Comments
Was the doctor professional and courteous to you and your child? Yes No Comments
Did cleanliness of our practice meet your expectations? Yes No
Were your financial matters handled in a timely and well addressed manner? Yes No
Would you refer your friends and family to us? Yes No Please comment on how we could make your visit better.
Please type "123" in the box below to complete submission: