Patient Survey Patient Name:    E-mail address:    How would you rate your overall visit? Excellent   Very Good   Average   Not so good   When your appointment was over, did you have a good understanding of your dental situation? Yes   Not really   I wish I knew more about my situation   Were your financial options explained to you? Yes   No   I already understand my financial options   Did you have to wait over 15 minutes past your appointment time to be seated? If so, how long? No   15 to 30 minutes   30 to 45 minutes   Over 45 minutes   Did the staff greet you properly? Yes   Not really   I don't recall   Cleanliness of Facility: Excellent   Very Good   Average   Not so good   Convenience of Hours Excellent   Very Good   Average   Not so good   Would you refer your friends and family to us? Yes   No   I'm not sure   Please comment on how we could make your visit better, new services you would like to see, or other ways we can make you feel more comfortable.   Forms HIPAA Notice of Privacy Practices Registration Form Health History Form
© 2008 Cosmetic & Family Dentistry

Web Hosting Provided by Maine Hosting Solutions