Survey

Name:

Email:

Please rate your office experience:

How would you rate your overall experience with our office?

Excellent

Good

Poor

Was your case handled to your satisfaction?

Excellent

Good

Poor

Were your questions answered satisfactorily?

Excellent

Good

Poor

Please rate the timeliness in which you were seen by the Doctor:

Excellent

Good

Poor

Please rate the timeliness in which you were seen by the Surgical Assistants:

Excellent

Good

Poor

Please rate the timeliness in which you were seen by the Hygienists:

Excellent

Good

Poor

Did you benefit from your visit to our office?

Yes

No

Comments?

How would you rate communication with our Reception (appointment, information) staff?

Excellent

Good

Poor

How would you rate communication with our Financial Coordinator?

Excellent

Good

Poor

How would you rate communication with our Surgical Assistants?

Excellent

Good

Poor

How would you rate communication with our Hygienists?

Excellent

Good

Poor

How would you rate communication with our Doctor?

Excellent

Good

Poor

Comments?

How would you rate the attitude of our staff?

Excellent

Good

Poor

If exceptional, in what area?

If poorly, in what area?

Was there a staff member(s) who has been particularly helpful? If so, please mention, so we can acknowledge them.

Yes

No

Employee Name?

Would you return to our office in the future?

Yes

No

Comments?

Would you recommend our office to others?

Yes

No

Comments?

Suggestions for Improvement:

Phone Number

Today's Date