Name:

Email:

1. May we send you information and announcements from time to time via e-mail? Yes No

2. How did you hear about us?

3. Were you seen in a timely manner? Yes No

4. Were you scheduled within 2 weeks from the time you called? Yes No
If not, how long?

4. Are you pleased with the service that you received? Yes No

5. Were your dental questions and concerns answered and explained thoroughly explained by the doctor? Yes No

6. How was the overall appearance of our staff and office?

7. Was our staff friendly, professional and helpful? Yes No

8. How was our staff on the telephone?

9. Did you know that we have the Waterlase Laser - for dental procedures? Yes No

10. Are you interested in Cosmetic services such as Invisalign, whitening or veneers? Yes No

11. Did you visit the patient education section on our web site? Yes No

12. Do your kids enjoy coming to our office? Yes No

13. How can we improve our relationship with your children?

14. Did you know we have a massage chair for patients, while they are waiting for their dental appointment? Yes No

15. Any other comments or suggestions?