Dental Office Patient Experience Check-in Form
Please complete this form to check in and help us improve your dental care experience.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Have you visited our dental office before?
*
Yes
No
What is the main reason for your visit today?
*
Please Select
Routine Check-up
Cleaning
Tooth Pain
Orthodontic Consultation
Other
Do you have any allergies or medical conditions we should be aware of?
Please rate your satisfaction with the following aspects of our dental office:
*
Rows
Staff Courtesy
Cleanliness
Waiting Time
Overall Experience
Very Satisfied
1
2
3
4
Satisfied
5
6
7
8
Neutral
9
10
11
12
Dissatisfied
13
14
15
16
Very Dissatisfied
17
18
19
20
Would you recommend our dental office to others?
*
Yes
No
Is there anything else you would like to share about your visit today?
Signature (Please sign to confirm your information and consent)
*
Check In
Check In
Should be Empty: