Patient Survey

Patient Name (optional)

E-mail address (optional)

Who were you here to visit today?
Dr. Smith Dr. Roy Dr. White Dr. Bazan Allison Kelli
Helen Laurie Cameron Other

How would you rate your overall visit?
Excellent Very Good Average Not so good NA

When your appointment was over did you have a good understanding of your dental situation?
Yes Not really I wish I knew more NA

Were your financial options explained to you?
Yes No I already understand my financial options NA

Did you have to wait past your appointment time to be seated? If so how long?
No 1 to 5 minutes 5 to 10 minutes 10 to 20 minutes Over 20 minutes NA

Did the staff greet you properly?
Yes Not really I don't recall NA

Would you refer your friends and family to 21st Century Dental?
Yes No I'm not sure

Please comment on anyone you met during your visit, things we could change, new services you would like to see, or other ways we can make you feel more comfortable