www.BurlesonOrtho.com

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1. On a scale of 1 to 10 (with 10 being excellent and 1 being very poor), please rate the following areas of our practice:

	1	2	3	4	5	6	7	8	9	10
Overall satisfaction with our doctor and staff	*On a scale of 1 to 10 (with 10 being excellent and 1 being very poor), please rate the following areas of our practice: Overall satisfaction with our doctor and staff 1	Overall satisfaction with our doctor and staff 2	Overall satisfaction with our doctor and staff 3	Overall satisfaction with our doctor and staff 4	Overall satisfaction with our doctor and staff 5	Overall satisfaction with our doctor and staff 6	Overall satisfaction with our doctor and staff 7	Overall satisfaction with our doctor and staff 8	Overall satisfaction with our doctor and staff 9	Overall satisfaction with our doctor and staff 10
Value (cost) of orthodontic treatment in our office	Value (cost) of orthodontic treatment in our office 1	Value (cost) of orthodontic treatment in our office 2	Value (cost) of orthodontic treatment in our office 3	Value (cost) of orthodontic treatment in our office 4	Value (cost) of orthodontic treatment in our office 5	Value (cost) of orthodontic treatment in our office 6	Value (cost) of orthodontic treatment in our office 7	Value (cost) of orthodontic treatment in our office 8	Value (cost) of orthodontic treatment in our office 9	Value (cost) of orthodontic treatment in our office 10
Physical environment / cleanliness of our facility	Physical environment / cleanliness of our facility 1	Physical environment / cleanliness of our facility 2	Physical environment / cleanliness of our facility 3	Physical environment / cleanliness of our facility 4	Physical environment / cleanliness of our facility 5	Physical environment / cleanliness of our facility 6	Physical environment / cleanliness of our facility 7	Physical environment / cleanliness of our facility 8	Physical environment / cleanliness of our facility 9	Physical environment / cleanliness of our facility 10
Convenience of appointment times	Convenience of appointment times 1	Convenience of appointment times 2	Convenience of appointment times 3	Convenience of appointment times 4	Convenience of appointment times 5	Convenience of appointment times 6	Convenience of appointment times 7	Convenience of appointment times 8	Convenience of appointment times 9	Convenience of appointment times 10
Greeting upon arrival	Greeting upon arrival 1	Greeting upon arrival 2	Greeting upon arrival 3	Greeting upon arrival 4	Greeting upon arrival 5	Greeting upon arrival 6	Greeting upon arrival 7	Greeting upon arrival 8	Greeting upon arrival 9	Greeting upon arrival 10
Telephone demeanor of our staff	Telephone demeanor of our staff 1	Telephone demeanor of our staff 2	Telephone demeanor of our staff 3	Telephone demeanor of our staff 4	Telephone demeanor of our staff 5	Telephone demeanor of our staff 6	Telephone demeanor of our staff 7	Telephone demeanor of our staff 8	Telephone demeanor of our staff 9	Telephone demeanor of our staff 10

2. When looking for an orthodontist, what was your biggest fear or frustration?

When looking for an orthodontist, what was your biggest fear or frustration?

3. What feature would you like to see added to our office?

What feature would you like to see added to our office?

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4. Are you aware that our office is currently accepting new patients?

Are you aware that our office is currently accepting new patients?   Yes No

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5. Do you feel positive enough about our practice to refer family or friends?

Do you feel positive enough about our practice to refer family or friends?   Yes No