Dental Clinic Performance Assessment Form
Please evaluate the performance of the dental clinic based on the criteria below.
Patient Name
First Name
Last Name
Date of Visit
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Friendliness
1
2
3
4
5
Cleanliness of Clinic
1
2
3
4
5
Wait Time
1
2
3
4
5
Quality of Treatment
1
2
3
4
5
Comments or Suggestions
Submit
Should be Empty: