Dental Tooth Extraction Patient Survey Form
Please share your experience with your recent dental tooth extraction. Your feedback helps us improve our care and service.
How would you rate your overall experience with your dental extraction visit?
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1
2
3
4
5
How comfortable did you feel during the extraction procedure?
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Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
How would you rate the clarity of the instructions you received before and after your extraction?
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1
2
3
4
5
How well did our team address your questions or concerns?
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Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
How would you describe your pain level in the first 24 hours after extraction?
*
No pain
Mild
Moderate
Severe
How easy was it to schedule your extraction appointment?
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Very difficult
1
2
3
4
Very easy
5
1 is Very difficult, 5 is Very easy
How likely are you to recommend our dental practice to others?
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Not likely
1
2
3
4
Extremely likely
5
1 is Not likely, 5 is Extremely likely
How satisfied are you with the aftercare support you received?
*
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Was the reason for your extraction clearly explained to you?
*
Yes
Somewhat
No
Please share any additional comments or suggestions to help us improve.
Submit Survey
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