After Visit Survey

All fields are required except comments.

Date of Visit:

Patient's Age:
Under 1818-3031-5051-6566+

Waiting time before staff noticed your arrival, helpfulness at front desk
ExcellentVery GoodAverageNot so good

Hygienists’ courtesy, concern for comfort, address treatment needs
ExcellentVery GoodAverageNot so goodDidn't see a hygientist this visit

Assistants’ attention to your needs, explanation of procedures, courtesy
ExcellentVery GoodAverageNot so goodDidn't see an assistant this visit

Dentists’ courtesy, concern for comfort, address treatment needs
ExcellentVery GoodAverageNot so goodDidn't see a dentist this visit

Explanation of insurance/financing
ExcellentVery GoodAverageNot so goodNot relevant this visit

Overall Assessment
ExcellentVery GoodAverageNot so good

Comments (describe good or bad experience):

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