ENGLISH SPANISH Patient Information Name: Date of Visit: Dr.: 1. Appointment Experience How easy was it to schedule your appointment? Very Easy Easy Neutral Difficult Very Difficult Were you seen on time? Yes No Was the doctor friendly and helpful? Yes Somewhat No How would you rate your dental/orthodontic treatment? Excellent Good Fair Poor Did we explain your treatment clearly? Yes Somewhat No Did you feel comfortable during your visit? Yes Somewhat No 2. Front Office Experience How would you rate our front desk staff? Excellent Good Fair Poor 3. Cleanliness & Environment How would you rate the cleanliness of our office? Excellent Good Fair Poor 4. Overall Experience Overall, how satisfied are you with your visit? Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Would you recommend our office to family and friends? Yes No 5. How did you hear about us? Friend / Family / Doctor Mail Social Media Other: Additional Feedback Thank you for your feedback! Submit Survey Patient Information Name: Date of Visit: Dr.: 1. Appointment Experience How easy was it to schedule your appointment? Very Easy Easy Neutral Difficult Very Difficult Were you seen on time? Yes No Was the doctor friendly and helpful? Yes Somewhat No How would you rate your dental/orthodontic treatment? Excellent Good Fair Poor Did we explain your treatment clearly? Yes Somewhat No Did you feel comfortable during your visit? Yes Somewhat No 2. Front Office Experience How would you rate our front desk staff? Excellent Good Fair Poor 3. Cleanliness & Environment How would you rate the cleanliness of our office? Excellent Good Fair Poor 4. Overall Experience Overall, how satisfied are you with your visit? Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Would you recommend our office to family and friends? Yes No 5. How did you hear about us? Friend / Family / Doctor Mail Social Media Other: Additional Feedback Thank you for your feedback! Submit Survey
