Dental Patient Experience Survey
Have you visited our oral care center?
Yes
No
How did you hear of us?
Friend/relative
Television advertisement
Brochures
Newspaper
Posters
Other
Please Specify
How many times have you visited us previously?
This is my first time
Only once
More than once
Only when my personal dentist is unavailable
How long have you been a regular patient with us?
Less than 1 year
1-2 years
3-4 years
5-9 years
9+ years
How often do you visit the dentist?
Quarterly
Every 6 months
Yearly
Only when I have pain
Other
Please specify
What is the name of the dentist who treated you?
First Name
Last Name
How satisfied are you with the dentist;'s attitude and behavior?
1
2
3
4
5
In which areas does our staff make you comfortable?
Value
Management of discomfort
Communication
Convenience
Quality
Financial arrangements
Organization
Hygiene treatment
Sincere concern
Waiting time
Other
Please specify
Would you recommend your friends and family have their dental work done with us?
Yes
No
Maybe
Please specify
Is there anything else we could do to improve your dental experience?
Submit
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