New Patient Survey

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1. Personal Information.

Personal Information.   Parent/Guardian Full Name:
Patient Full Name:
Email Address

2. Visit:

	MM		DD		YYYY
Date:	Visit:   Date:   Month	/	Day	/	Year

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3. Was your initial call handled efficiently?

Was your initial call handled efficiently?   Yes No

If NO, please explain.

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4. Did the doctor or hygienist listen carefully to your concerns?

Did the doctor or hygienist listen carefully to your concerns?   Yes No

If NO, please explain.

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5. If your child needed treatment, were you able to understand why there is a need for treatment and what has been recommended?

If your child needed treatment, were you able to understand why there is a need for treatment and what has been recommended?   Yes No

If NO, please explain.

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6. Was our team caring, polite and eager to help?

Was our team caring, polite and eager to help?   Yes No

If NO, please explain.

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7. Did the cleanliness and infection control of our practice meet your expectations?

Did the cleanliness and infection control of our practice meet your expectations?   Yes No

If NO, please explain.

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8. During checkout, were all of your financial and insurance questions answered?

During checkout, were all of your financial and insurance questions answered?   Yes No

If NO, please explain.

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9. Did your child enjoy his/her visit?

Did your child enjoy his/her visit?   Yes No

If NO, please explain.

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10. What do you think about our practice?

What do you think about our practice?

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11. If you have any suggestions regarding how we could improve our services, we would appreciate your input. Please enter them below:

If you have any suggestions regarding how we could improve our services, we would appreciate your input. Please enter them below:

12. Would you recommend your family/friends to our practice?

Would you recommend your family/friends to our practice?   Yes No

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13. Are there any team member(s) that you would like recognize for outstanding customer service?

Are there any team member(s) that you would like recognize for outstanding customer service?