Thank you for participating in our Make a Smile Satisfaction Survey. Your input is important to us.

1. Please answer these questions about your last visit

	Dissatisfied 1	2	3	4	Outstanding 5
It was easy to schedule a convenient appointment.	*Please answer these questions about your last visit It was easy to schedule a convenient appointment. Dissatisfied 1	It was easy to schedule a convenient appointment. 2	It was easy to schedule a convenient appointment. 3	It was easy to schedule a convenient appointment. 4	It was easy to schedule a convenient appointment. Outstanding 5
Upon arrival I was greeted courteously.	Upon arrival I was greeted courteously. Dissatisfied 1	Upon arrival I was greeted courteously. 2	Upon arrival I was greeted courteously. 3	Upon arrival I was greeted courteously. 4	Upon arrival I was greeted courteously. Outstanding 5
My registration was easy and efficient.	My registration was easy and efficient. Dissatisfied 1	My registration was easy and efficient. 2	My registration was easy and efficient. 3	My registration was easy and efficient. 4	My registration was easy and efficient. Outstanding 5
The waiting time in the reception area was very reasonable.	The waiting time in the reception area was very reasonable. Dissatisfied 1	The waiting time in the reception area was very reasonable. 2	The waiting time in the reception area was very reasonable. 3	The waiting time in the reception area was very reasonable. 4	The waiting time in the reception area was very reasonable. Outstanding 5
I felt the doctor and team listened and understood my dental concerns.	I felt the doctor and team listened and understood my dental concerns. Dissatisfied 1	I felt the doctor and team listened and understood my dental concerns. 2	I felt the doctor and team listened and understood my dental concerns. 3	I felt the doctor and team listened and understood my dental concerns. 4	I felt the doctor and team listened and understood my dental concerns. Outstanding 5
I feel I understand the treatment prescribed and all of my questions were answered to my satisfaction.	I feel I understand the treatment prescribed and all of my questions were answered to my satisfaction. Dissatisfied 1	I feel I understand the treatment prescribed and all of my questions were answered to my satisfaction. 2	I feel I understand the treatment prescribed and all of my questions were answered to my satisfaction. 3	I feel I understand the treatment prescribed and all of my questions were answered to my satisfaction. 4	I feel I understand the treatment prescribed and all of my questions were answered to my satisfaction. Outstanding 5
Your overall satisfaction with the doctor's and/or assistant's sensitivity to you and your child's needs.	Your overall satisfaction with the doctor's and/or assistant's sensitivity to you and your child's needs. Dissatisfied 1	Your overall satisfaction with the doctor's and/or assistant's sensitivity to you and your child's needs. 2	Your overall satisfaction with the doctor's and/or assistant's sensitivity to you and your child's needs. 3	Your overall satisfaction with the doctor's and/or assistant's sensitivity to you and your child's needs. 4	Your overall satisfaction with the doctor's and/or assistant's sensitivity to you and your child's needs. Outstanding 5
Please rate the overall courtesy and friendliness of the doctor and the dental team.	Please rate the overall courtesy and friendliness of the doctor and the dental team. Dissatisfied 1	Please rate the overall courtesy and friendliness of the doctor and the dental team. 2	Please rate the overall courtesy and friendliness of the doctor and the dental team. 3	Please rate the overall courtesy and friendliness of the doctor and the dental team. 4	Please rate the overall courtesy and friendliness of the doctor and the dental team. Outstanding 5
I enjoyed the office environment.	I enjoyed the office environment. Dissatisfied 1	I enjoyed the office environment. 2	I enjoyed the office environment. 3	I enjoyed the office environment. 4	I enjoyed the office environment. Outstanding 5
The reception area, restroom and treatment rooms are clean and comfortable.	The reception area, restroom and treatment rooms are clean and comfortable. Dissatisfied 1	The reception area, restroom and treatment rooms are clean and comfortable. 2	The reception area, restroom and treatment rooms are clean and comfortable. 3	The reception area, restroom and treatment rooms are clean and comfortable. 4	The reception area, restroom and treatment rooms are clean and comfortable. Outstanding 5
How would you rate your overall satisfaction with your visit?	How would you rate your overall satisfaction with your visit? Dissatisfied 1	How would you rate your overall satisfaction with your visit? 2	How would you rate your overall satisfaction with your visit? 3	How would you rate your overall satisfaction with your visit? 4	How would you rate your overall satisfaction with your visit? Outstanding 5

2. Please answer the following questions about Make A Smile

	Yes	No
Was your child's treatment fully explained to your satisfaction?	*Please answer the following questions about Make A Smile Was your child's treatment fully explained to your satisfaction? Yes	Was your child's treatment fully explained to your satisfaction? No
Was your child's dental treatment completed to your satisfaction?	Was your child's dental treatment completed to your satisfaction? Yes	Was your child's dental treatment completed to your satisfaction? No
Were all of your financial and insurance questions answered clearly at check out?	Were all of your financial and insurance questions answered clearly at check out? Yes	Were all of your financial and insurance questions answered clearly at check out? No
Would you recommend Make A Smile Children’s Dental to others?	Would you recommend Make A Smile Children’s Dental to others? Yes	Would you recommend Make A Smile Children’s Dental to others? No

3. Is there anything else you'd like to tell us about your visit?

Is there anything else you'd like to tell us about your visit?

4. If you would like us to contact you, please provide your name and phone number or email address.

If you would like us to contact you, please provide your name and phone number or email address.

Make A Smile Survey

1. Please answer these questions about your last visit

2. Please answer the following questions about Make A Smile

3. Is there anything else you'd like to tell us about your visit?

4. If you would like us to contact you, please provide your name and phone number or email address.