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Patient Survey

This survey will remain anonymous, so please give us your honest input. We appreciate your feedback, and your participation will enter you to win a free In-Office Whitening procedure.

1. What was the reason for your visit?
To establish yourself with a new dentist
Interest in Cosmetic Dentistry
Hygiene Visit
TMJ Concerns
Repeat Visit

2. Please write the name of the doctor or hygienist who you had an appointment with.


3. My experience at Dream Smile Dental was of a high quality service
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


4. The appearance of the waiting room was neat and clean
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


5. The appearance of the operatory was sterile and neat
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


6. The manner of the Doctors was professional and friendly
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


7. The manner of the Front Desk Staff was professional and friendly
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


8. The manner of the Hygienist and Dental Assistants was professional and friendly
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


9. I feel I left with a clear understanding of the doctor's recommended treatment and was educated on the dentistry proposed
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


10. I feel as though I fully understand my financial obligations and the finance options at Dream Smile Dental
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain


11. I am satisfied with the manner in which my appointment was scheduled and confirmed
Strongly Agree Agree Neutral Disagree Strongly Disagree
Please explain
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