$5 Dental Dollars for 4 minutes of your time - Thanks for being an “A” Referrer!
*
1.
Which of these would you rate highest as an upcoming prize for our quarterly referral giveaway? (Pinecrestdds.com/giveaways)
(Required.)
Deluxe Spa package for 2
Paddleboard
Getaway for 2 to Park City
6 Month Smiles cosmetic braces
Caribbean Cruise for 2
Disneyland Package
Utah Jazz Lower Bowl Package
Dental implant
Apple Watch
Traeger Grill
Deluxe YETI Cooler
Costco $500 gift card
Disneyland Vacation for 4
Utah Football Tickets for 4
BYU Football Tickets for 4
Other (please specify)
*
2.
Which of these would you rate 2nd highest as an upcoming prize for our quarterly referral giveaway? (Pinecrestdds.com/giveaways)
(Required.)
Deluxe Spa package for 2
Paddleboard
Getaway for 2 to Park City
6 Month Smiles cosmetic braces
Caribbean Cruise for 2
Disneyland Package
Utah Jazz Lower Bowl Package
Dental implant
Apple Watch
Traeger Grill
Deluxe YETI Cooler
Costco $500 gift card
Disneyland Vacation for 4
Utah Football Tickets for 4
BYU Football Tickets for 4
Other (please specify)
*
3.
Which of these would you rate 3rd highest as an upcoming prize for our quarterly referral giveaway? (Pinecrestdds.com/giveaways)
(Required.)
Deluxe Spa package for 2
Paddleboard
Getaway for 2 to Park City
6 Month Smiles cosmetic braces
Caribbean Cruise for 2
Disneyland Package
Utah Jazz Lower Bowl Package
Dental implant
Apple Watch
Traeger Grill
Deluxe YETI Cooler
Costco $500 gift card
Disneyland Vacation for 4
Utah Football Tickets for 4
BYU Football Tickets for 4
Other (please specify)
*
4.
In the past or present, which of these are the MOST IMPORTANT reasons as to why you’ve avoided or put off regular dental care? (Check all that apply)
(Required.)
Fear of dental work
Anxiety
Cost
Making time
Lack of insurance
No payment options
Not seeing regular dental visits as important enough
Other (please specify)
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5.
Since you’ve been a patient at Pinecrest Dental, how have we helped you the MOST regarding your dental health? (Check all that apply)
(Required.)
Enhancing the appearance of your smile
Improved how you feel about the dentist
Helped improve you home hygiene routine
Playing an important role in your overall health maintenance
Susan G. Breast Cancer Awareness
Made your dental visits more comfortable
Other (please specify)
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6.
How would you rate the service at our office? (check all that apply)
(Required.)
High Quality
Focused on your experience
Unique
Good value for the money
Personalized
Friendly Staff
Multiple options given for your care
Convenient Payment Plans
Convenient Hours
Other (please specify)
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7.
What do you feel would be the most valuable referral offer for your friends, family or coworkers when they become a new guest at our practice? (Check all that apply)
(Required.)
Free consulatation
Movie tickets
Quarterly giveaways (pinecrestdds.com/giveaways)
Dinner
Free copy of Dr. Williams new book, Reason to Smile: 11 keys to your best oral health every
Complementary oral sedation
Charity donation
Other (please specify)
8.
Your name (required to receive the $5 Dental Dollars credit) - your answers will be kept confidential!