New Patient Survey Apex Dental Group

1. Default Section

Question Title

* 1. At what time were you seated for your appointment?

10 minutes or more early

5 minutes early

Seated on time

5 minutes late

10 minutes or more late

Question Title

* 2. What did you like most about your visit?

Question Title

* 3. What did you like the least about your visit?

Question Title

* 4. Did our team members improve your dental knowledge and communicate in a friendly, polite and courteous manner?

Yes

Your comments:

Question Title

* 5. How would you rate the thoroughness of the doctor’s treatment?

Outstanding

Good

Average

Below Average

Unacceptable

Question Title

* 6. How would you rate the thoroughness of the hygienist’s and assistant's treatment?

Outstanding

Good

Average

Below Average

Unacceptable

Question Title

* 7. Was your treatment comfortable?

Yes

Question Title

* 8. Did we inform you (prior to treatment) of estimated costs?

Yes

Question Title

* 9. Was your visit to our office a pleasant and positive experience?

Outstanding

Good

Average

Below Average

Unacceptable

Question Title

* 10. How can we improve our service to you?

Question Title

* 11. Would you recommend our practice to family and friends?

Yes

Your comments / referral:

Question Title

* 12. Would you like to leave comments with Dr Kitzmiller concerning you treatment?

Yes

Your comments:

Question Title

* 13. This survey is anonymous, but if you would like to speak to Dr Kitzmiller about your visit, please give us your contact information below.

Name:

Company:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

Question Title

* 1. At what time were you seated for your appointment?

Question Title

* 2. What did you like most about your visit?

Question Title

* 3. What did you like the least about your visit?

Question Title

* 4. Did our team members improve your dental knowledge and communicate in a friendly, polite and courteous manner?

Question Title

* 5. How would you rate the thoroughness of the doctor’s treatment?

Question Title

* 6. How would you rate the thoroughness of the hygienist’s and assistant's treatment?

Question Title

* 7. Was your treatment comfortable?

Question Title

* 8. Did we inform you (prior to treatment) of estimated costs?

Question Title

* 9. Was your visit to our office a pleasant and positive experience?

Question Title

* 10. How can we improve our service to you?

Question Title

* 11. Would you recommend our practice to family and friends?

Question Title

* 12. Would you like to leave comments with Dr Kitzmiller concerning you treatment?

Question Title

* 13. This survey is anonymous, but if you would like to speak to Dr Kitzmiller about your visit, please give us your contact information below.

Question Title

* 14. Thank you for sharing your honest opinions and concerns in this evaluation. Can we improve our survey? Please comment below: