Dr Kim July 2011 Survey

1. How did you hear about us?

How did you hear about us? Yellow pages

Friend of Family member

Community newsletter

Internet (Our Town)

Don’t remember

Other (please specify)

2. What made you choose us as your dental office? (Please choose all that apply)

What made you choose us as your dental office? (Please choose all that apply) Friendly Staff

Quality of Work

Great Service

Location

Up-to-date Technology in office

Comfort of dental care

Other (please specify)

3. Please rate your overall satisfaction with the services you receive from our office

	Not Satisfied									Very Satisfied
How satisfied are you with our service?	*Please rate your overall satisfaction with the services you receive from our office How satisfied are you with our service? Not Satisfied	How satisfied are you with our service?	How satisfied are you with our service?	How satisfied are you with our service?	How satisfied are you with our service?	How satisfied are you with our service?	How satisfied are you with our service?	How satisfied are you with our service?	How satisfied are you with our service?	How satisfied are you with our service? Very Satisfied

4. If there was any product or service you would like us to offer – what would it be? Please be as specific as you can

If there was any product or service you would like us to offer – what would it be? Please be as specific as you can

5. How important are the following to you and/or your family? ( 1 = not important at all - 5 = very important)

	1. Not Important	2.	3.	4.	5. Very Important
Location of office	*How important are the following to you and/or your family? ( 1 = not important at all - 5 = very important) Location of office 1. Not Important	Location of office 2.	Location of office 3.	Location of office 4.	Location of office 5. Very Important
Friendliness of staff and Dentist	Friendliness of staff and Dentist 1. Not Important	Friendliness of staff and Dentist 2.	Friendliness of staff and Dentist 3.	Friendliness of staff and Dentist 4.	Friendliness of staff and Dentist 5. Very Important
Pain-Free treatment	Pain-Free treatment 1. Not Important	Pain-Free treatment 2.	Pain-Free treatment 3.	Pain-Free treatment 4.	Pain-Free treatment 5. Very Important
Ability to use your insurance carrier	Ability to use your insurance carrier 1. Not Important	Ability to use your insurance carrier 2.	Ability to use your insurance carrier 3.	Ability to use your insurance carrier 4.	Ability to use your insurance carrier 5. Very Important
Availability by phone 24-hours/day	Availability by phone 24-hours/day 1. Not Important	Availability by phone 24-hours/day 2.	Availability by phone 24-hours/day 3.	Availability by phone 24-hours/day 4.	Availability by phone 24-hours/day 5. Very Important
Price / value for services received	Price / value for services received 1. Not Important	Price / value for services received 2.	Price / value for services received 3.	Price / value for services received 4.	Price / value for services received 5. Very Important
Professional knowledge / certifications of Dentist	Professional knowledge / certifications of Dentist 1. Not Important	Professional knowledge / certifications of Dentist 2.	Professional knowledge / certifications of Dentist 3.	Professional knowledge / certifications of Dentist 4.	Professional knowledge / certifications of Dentist 5. Very Important
Professional knowledge / certifications of Hygienist	Professional knowledge / certifications of Hygienist 1. Not Important	Professional knowledge / certifications of Hygienist 2.	Professional knowledge / certifications of Hygienist 3.	Professional knowledge / certifications of Hygienist 4.	Professional knowledge / certifications of Hygienist 5. Very Important
Offering of the latest technology / services	Offering of the latest technology / services 1. Not Important	Offering of the latest technology / services 2.	Offering of the latest technology / services 3.	Offering of the latest technology / services 4.	Offering of the latest technology / services 5. Very Important

Other (please specify)

6. On your last visit to our office, please rate the following…

	1. Not Satisfied	2.	3.	4.	5. Very Satisfied
Friendly greeting	*On your last visit to our office, please rate the following… Friendly greeting 1. Not Satisfied	Friendly greeting 2.	Friendly greeting 3.	Friendly greeting 4.	Friendly greeting 5. Very Satisfied
Music in the office/treatment rooms	Music in the office/treatment rooms 1. Not Satisfied	Music in the office/treatment rooms 2.	Music in the office/treatment rooms 3.	Music in the office/treatment rooms 4.	Music in the office/treatment rooms 5. Very Satisfied
Understanding of your clinical plan – meet your needs, wants, desires	Understanding of your clinical plan – meet your needs, wants, desires 1. Not Satisfied	Understanding of your clinical plan – meet your needs, wants, desires 2.	Understanding of your clinical plan – meet your needs, wants, desires 3.	Understanding of your clinical plan – meet your needs, wants, desires 4.	Understanding of your clinical plan – meet your needs, wants, desires 5. Very Satisfied
Understanding of the financial arrangements – understanding costs and payment options	Understanding of the financial arrangements – understanding costs and payment options 1. Not Satisfied	Understanding of the financial arrangements – understanding costs and payment options 2.	Understanding of the financial arrangements – understanding costs and payment options 3.	Understanding of the financial arrangements – understanding costs and payment options 4.	Understanding of the financial arrangements – understanding costs and payment options 5. Very Satisfied

7. Would you recommend your friends and family have their dental work done with us?

Would you recommend your friends and family have their dental work done with us? Yes

Other (please specify)

8. Have you ever considered teeth whitening?

Have you ever considered teeth whitening? Yes

9. Under what circumstances would you consider changing your dental service provider?

Under what circumstances would you consider changing your dental service provider?

10. If you'd be willing to provide your name and/or email address, we'd love the chance to say "Thank You" for sharing your thoughts. No obligation.

If you'd be willing to provide your name and/or email address, we'd love the chance to say "Thank You" for sharing your thoughts. No obligation.

Dr Kim July 2011Exit this survey

1. How did you hear about us?

2. What made you choose us as your dental office? (Please choose all that apply)

3. Please rate your overall satisfaction with the services you receive from our office

4. If there was any product or service you would like us to offer – what would it be? Please be as specific as you can

5. How important are the following to you and/or your family? ( 1 = not important at all - 5 = very important)

6. On your last visit to our office, please rate the following…

7. Would you recommend your friends and family have their dental work done with us?

8. Have you ever considered teeth whitening?

9. Under what circumstances would you consider changing your dental service provider?

10. If you'd be willing to provide your name and/or email address, we'd love the chance to say "Thank You" for sharing your thoughts. No obligation.

Dr Kim July 2011
Exit this survey