* 1. Please Rate the following:

  Strongly Disagree Disagree Neutral Agree Strongly Agree
I was comfortable during each step of my care.
At all times during my care, it was explained to me what was happening and why.
All my questions and concerns were addressed.
I understood and was comfortable with my recommended treatment before moving onto the next step of my care.
All of my financial concerns were addressed before I was scheduled for surgery.
I had sufficient time to think through all of the information presented to me.
My home care questions and concerns were addressed to my satisfaction.
I felt truly cared for throughout my treatment.

* 2. How likely is it that you would recommend Sharma Oral Surgery to your friends & family?

0 = Not At All Likely, 10 = Extremely Likely.

* 3. Please let us know how we can make improvements to better care for our patients.

* 4. Do you have any additional comments for us?

* 5. Please provide us with additional information about yourself so we can send you a token of our appreciation.

* 6. Reason for your visit:

* 7. How did you hear about us?

* 8. Please provide your referring dentist/doctor's name: