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* 1. How did you first hear about us?

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

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

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* 4. How often do you make dental visits?

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

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

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

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

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* 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)

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* 9. Have you ever considered sedation dentistry?

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* 10. Have you ever considered teeth whitening?

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* 11. Into what age group do you fall?

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

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

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