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In order to find out how we are meeting your needs, we are asking our patients a few questions about
the care they have received. Please be honest in your answers. Your comments will be held in strict
confidence and you do not have to sign your name unless you want to. We plan to use your
suggestions to make our service to you and your family even better. Thank you for your comments.

* 1. What is your age?

* 2. What is your gender?

* 3. In the past year, how often have you visited your dentist?

* 4. My dental treatment status is:

* 5. How easy is it to schedule dental emergency appointments with the front desk?

* 6. The scheduling coordinator was polite and helpful.

* 7. I received a reminder of each of my appointments.

* 8. Was it easy to schedule an appointment convenient for your schedule?

* 9. Appointment options were given that suited my schedule.

* 10. How friendly was the front desk staff?

* 11. I was seen on time for my appointments; if not, I was given a reason for the
delay.

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