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Patient Satisfaction Survey

We are committed to providing you the highest quality of patient care and service.
Your feedback is important to us in fulfilling our commitment. Please take a moment to fill out this Patient Survey form and let us know how we are doing.

Tell us about your appointment:

Date of visit:   
Time of visit:  
Clinic visited:  
Dental provider:  

Personal Information (optional):
 

 Name:  
 Address:  
 
City:    State:    Zip:  
 
 Email:   
 May we contact regarding this survey? Yes   No

How would you rate your experience? (please check one)          
  Excellent Good Fair Poor N/A
Your dental problem was addressed today
Appointment availability
Promptness of appointment
We reviewed your oral care and nutrition
Overall courtesy of faculty/student/staff
Cleanliness of treatment area
Overall satisfaction of the clinic


  Yes No
I am comfortable with the precautions taken to protect me from the spread of infectious disease.
I know where to call if I have a dental emergency 24 hours a day, 7 days a week.
Treatment procedures (including alternatives, risks, and treatment costs) were explained to me.

Was there anyone that went out of their way for you or made your dental visit more comfortable?
Is there something we did well or could do better?