Survey

Select your privacy
You may use my first name and comments
You may use my comments, but not my name
Don’t use my comments or my name

Your name (Optional)

When was your appointment?
Within the last week
Within the last month
Did not have one
Would rather not say

Your visit was for:
Examination
Treatment (fillings, crown, root canal, etc.)
Neither

How long did you wait before you were seen?
Less than 5 minutes
5-10 minutes
11-20 minutes
21-30 minutes
more than 30 minutes

Was the time you waited:
Longer
Shorter
As expected

Did our front office person make you feel welcome?
Yes
No
No opinion

Did our dental assistant make you feel comfortable?
Yes
No
No opinion

The staff were knowledgeable.
Strongly Agree
Agree
No opinion
Disagree
Strongly Disagree

Did Dr. Lord meet your dental health needs?
Yes
No
No opinion

Do you feel the purpose of your visit was fulfilled?
Yes
No

Do you feel you were given all the options for your treatment plan?
Yes
No
Not applicable

Do you feel like you participated in choosing your planned treatment?
Yes
No
Not applicable

How likely are you to recommend our practice to a friend or family member?
Very likely
Likely
Neutral
Not likely
Never

On a scale from 1 to 10, how likely are you to return to our office?
10-Will definately return
9
8
7
6
5-Undecided
4
3
2
1-Will never return

What was the #1 reason for choosing us?
Evening appointments
Saturday appointments
Location
Takes my insurance
Referred by friend

What is the most important quality you look for when choosing a dental practice?

Please use the space below to share any of your opinions (positive or negative) to help us better serve you and others: