Your opinion is important to us please let us know how we did.

Your opinion is important to us, please let us know how we did.

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* 1. This survey can remain anonymous, but if you would like to leave your name, please do so.

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* 2. How do you rate communicating with us?

Other (please specify)

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* 3. How would you rate your overall visit?

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* 4. Were you greeted Courteously and professionally by our Front desk's staff?

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* 5. Were you greeted and seated in a professional manner?

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* 6. How were you happy with the treatment you received?

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* 7. If you had another chance would you prefer to see the same Doctor/ Hygienist?

Yes

No

Who did you see today?

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* 8. The best compliment we can receive is a referral would you recommend us to a friend or a family member?

Yes

No

If No please let us know what can we do to change that?

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* 9. We will be glad to hear any further comments

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* 10. If you have any concerns about your visit would you like Dr. Salama to contact you. If so please leave a contact that we can reach you at.

Name

Email Address

Phone Number