Patient Name:*
Email Address:*
Date of your last visit:
How was the treatment you received: -- Select -- Excellent Very Good Average Poor
How comfortable were you during the treatment you received: -- Select -- Very Not so comfortable Uncomfortable
Was your treatment explained to you so that you have a clear understanding of your dental situation: -- Select -- Yes No
Were your financial options explained to you?: -- Select -- Yes No, I already understand my financial options
How long did you wait before being seated in a room?: -- Select -- 0 minutes / no wait 15 minutes 30 minutes 45 minutes Longer
Would you refer your friends and family to us?: -- Select -- Yes No Maybe
Please comment below on how we could make your next visit better and more comfortable. Thank you:
