Patient Care Optimization Survey

Patient Feedback

Please take a few moments to let us know how we can better serve you!
 
1. On a scale of 1 to 10, please rate the friendliness and helpfulness of the front desk staff:
1 2 3 4 5 6 7 8 9 10
Lowest
 
2. Were you greeted at the front desk when you first walked up to the window?
Yes
No
 
3. On a scale of 1 to 10, please rate the friendliness and helpfulness of the dental assistant:
1 2 3 4 5 6 7 8 9 10
Lowest
 
4. On a scale of 1 to 10, please rate your comfort level during your dental procedure:
1 2 3 4 5 6 7 8 9 10
Lowest
 
5. On a scale of 1 to 10, please rate how well you understood your dental procedure:
1 2 3 4 5 6 7 8 9 10
Lowest
 
6. Which dentist did you work with today?
 
7. Which dental hygienist did you work with at your last cleaning appointment?
 
8. What procedure(s) did you get done at your most recent visit? (please check all that apply)
Filling
Extraction
Root Canal
Crown or Bridge
Veneer
Cleaning
Other
 
9. What suggestions do you have to make your next appointment more enjoyable? (please be as detailed as possible!)
 
10. Would you recommend our practice to your family and friends?
Yes
No
 
11. On a scale of 1 to 10, please rate your overall experience at the practice of Dr. Marcucci and Dr. Altomari:
1 2 3 4 5 6 7 8 9 10
Lowest
 
12. OPTIONAL: Please leave your name and email address (this information will not be given, shared, or sold to anyone, but is for internal use only).
Powered by: sourceforge.net/projects/phpesp
Terms of Use | Privacy Statement © 2009, 2010 Marcucci Dental. All rights reserved