Dental Care Survey

1. How did you first hear about us?

How did you first hear about us? Friend or Family member

Yellow pages

Radio ad

Don't Remember

Community newsletter

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) Quality of work

Price

Location

Great Service

Friendly Staff

Up to date Technology in the office

Other (please specify)

3. How long have you been a regular patient with us?

How long have you been a regular patient with us? Less than 1 year

1-2 years

3-4 years

5-9 years

10-19 years

20+ years

4. How often do you make dental visits?

How often do you make dental visits? Quarterly

Every 6 Months

Yearly

Only when I have pain

Other (please specify)

5. How do you rate us in the following areas:

	Extremely Poor	Poor	Fair	Good	Excellent	N/A
Location of the office	*How do you rate us in the following areas: Location of the office Extremely Poor	Location of the office Poor	Location of the office Fair	Location of the office Good	Location of the office Excellent	Location of the office N/A
Business hours	Business hours Extremely Poor	Business hours Poor	Business hours Fair	Business hours Good	Business hours Excellent	Business hours N/A
Friendliness of staff	Friendliness of staff Extremely Poor	Friendliness of staff Poor	Friendliness of staff Fair	Friendliness of staff Good	Friendliness of staff Excellent	Friendliness of staff N/A
Skill of hygienist and support staff	Skill of hygienist and support staff Extremely Poor	Skill of hygienist and support staff Poor	Skill of hygienist and support staff Fair	Skill of hygienist and support staff Good	Skill of hygienist and support staff Excellent	Skill of hygienist and support staff N/A
Skill of your dentist	Skill of your dentist Extremely Poor	Skill of your dentist Poor	Skill of your dentist Fair	Skill of your dentist Good	Skill of your dentist Excellent	Skill of your dentist N/A
Pain control	Pain control Extremely Poor	Pain control Poor	Pain control Fair	Pain control Good	Pain control Excellent	Pain control N/A
Cost of services	Cost of services Extremely Poor	Cost of services Poor	Cost of services Fair	Cost of services Good	Cost of services Excellent	Cost of services N/A
Handling of insurance claims	Handling of insurance claims Extremely Poor	Handling of insurance claims Poor	Handling of insurance claims Fair	Handling of insurance claims Good	Handling of insurance claims Excellent	Handling of insurance claims N/A
Supplying you with information about your dental care	Supplying you with information about your dental care Extremely Poor	Supplying you with information about your dental care Poor	Supplying you with information about your dental care Fair	Supplying you with information about your dental care Good	Supplying you with information about your dental care Excellent	Supplying you with information about your dental care N/A
Your treatment options being well explained	Your treatment options being well explained Extremely Poor	Your treatment options being well explained Poor	Your treatment options being well explained Fair	Your treatment options being well explained Good	Your treatment options being well explained Excellent	Your treatment options being well explained N/A
Supplying you with information on new technology and services we provide	Supplying you with information on new technology and services we provide Extremely Poor	Supplying you with information on new technology and services we provide Poor	Supplying you with information on new technology and services we provide Fair	Supplying you with information on new technology and services we provide Good	Supplying you with information on new technology and services we provide Excellent	Supplying you with information on new technology and services we provide N/A

6. In which areas does our staff make you feel comfortable? (Please choose all that apply)

In which areas does our staff make you feel comfortable? (Please choose all that apply) Quality

Value

Service

Financial arrangements

Hygiene treatment

Understanding of our sterilization practices

Communication

Making you feel special

Convenience

Waiting time

Management of discomfort

Organization

Sincere concern

Other (please specify)

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

Maybe (please specify)

8. What is the best way to communicate with you if we get new services or have specials on the current ones? (Please choose all that apply)

What is the best way to communicate with you if we get new services or have specials on the current ones? (Please choose all that apply) Newspaper ad

Mail

Dentist newsletter

Sign on building

Community newsletter

Other (please specify)

9. Have you ever considered sedation dentistry?

Have you ever considered sedation dentistry? Yes

I am not sure what that is exactly.

10. Have you ever considered teeth whitening?

Have you ever considered teeth whitening? Yes

11. Into what age group do you fall?

Into what age group do you fall? 20 and under

21 to 40

41 to 60

61 and over

12. What is something we could do to say thank you for referring others to our office? (Please choose all that apply)

What is something we could do to say thank you for referring others to our office? (Please choose all that apply) Free dental hygiene products

Gift certificate to local restaurant

Tickets to a sporting event

No need to do anything

Gift certificate for dental services

Discount off dental services

Gift certificate to local salon

Other (please specify)

13. Is there anything else we could do to improve your dental experience?

Is there anything else we could do to improve your dental experience?