In order to find out how we are meeting your needs, we are asking our patients about the care they have received. Please be honest in your responses. Your responses will be held in strict confidence. Thank you.
Please complete items 1 - 8 to describe yourself:

* 1. Age

* 2. Gender

* 3. Race

* 4. Marital Status

* 5. Do you have dental insurance?

* 6. What is the main reason you became a patient?

* 7. How were you referred to SDM?

* 8. How long have you been receiving treatment?


Please let us know how well we are doing in the following areas:

* 9. Appointments

  Poor Fair OK Good Great
Easy to make
Options were given
Provided in a reasonable time frame

* 10. Facility

  Poor Fair OK Good Great
Neat and clean building
Comfortable and safe
Hours of operation
Parking

* 11. Staff

  Poor Fair OK Good Great
Friendly and helpful

* 12. Provider / Student, Resident, Hygienist

  Poor Fair OK Good Great
Listens to you
Treats me with dignity and compassion
Takes enough time with you
Explains procedures
Gives good advice and treatment
Utilizes proper infection control techniques

* 13. Faculty

  Poor Fair OK Good Great
Provided timely instruction/assistance
Gave appropriate student guidance
Remained in clinic until treatment was complete
Treats me with dignity and compassion
Utilizes proper infection control techniques
Friendly and helpful

* 14. Treatment

  Poor Fair OK Good Great
Quality of care compared to elsewhere

* 15. Payment / Billing

  Poor Fair OK Good Great
Reasonable fees
Charges explained

* 16. Confidentiality

  Poor Fair OK Good Great
Personal Information Kept Private

* 17. Likelihood of Referring Others

* 18. Reason for discharge (if applicable)

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