Dental Patient Feedback Form
Patient Information:
Name
First Name
Last Name
Date of visit
-
Month
-
Day
Year
Date
Appointment Time
Dentist/Provider
Clinic Location
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment Experience:
Was your appointment scheduled promptly and conveniently?
Yes
No
If no, please specify any issues or concerns
Did you receive a reminder notification before your appointment?
Yes
No
If yes, how did you receive the reminder?
Text message
Email
Phone call
Rate your overall satisfaction with the appointment scheduling process
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
How would you rate the friendliness and professionalism of the front desk staff?
Poor
1
2
3
4
Excellent
5
1 is Poor , 5 is Excellent
Were your insurance and payment questions addressed to your satisfaction?
Yes
No
If no, please specify any issues or concerns
Were you seen by your dentist/provider in a timely manner?
Yes
No
If no, please specify any delays experienced
How would you rate the communication and explanation of your dental treatment plan by your dentist/provider?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Were your treatment preferences and concerns addressed during the appointment?
Yes
No
If no, please specify any unaddressed concerns
How would you rate the cleanliness and comfort of the clinic waiting area and treatment rooms?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Were you satisfied with the overall ambiance and atmosphere of the clinic?
Yes
No
If no, please specify any areas for improvement
Based on your visit today, would you recommend our dental clinic to friends or family?
Yes
No
If no, please specify any reasons for not recommending
Please share any additional comments, suggestions, or feedback about your experience at our dental clinic.
Give Us Your Feedback
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