Comment Form

Orthodontic Patient Satisfaction Survey

We strive to always provide the best quality of treatment and personal care for our patients. In order to help us do so, we would like to know how you feel about our services. Please take a few minutes to answer these questions and assist us to give you, and all our patients, the best service we can.

Please check the number which best describes each of the following:

5=Excellent 4=Very Good 3=Average 2=Below Average 1=Poor

1. How effective and clear were we in explaining your treatment plan?

Doctor 5 4 3 2 1

Staff 5 4 3 2 1

Comments:

2. Are we courteous, friendly and polite?

Doctor 5 4 3 2 1

Staff 5 4 3 2 1

Comments:

3. Is our office clean, neat, and professional looking?

5 4 3 2 1

Comments:

4. During treatment, are we gentle, competent and careful?

Doctor 5 4 3 2 1

Staff 5 4 3 2 1

Comments:

5. Are our fees, financial arrangements reasonable for you?

5 4 3 2 1

Comments:

6. likely would you be to recommend us to your friends and family?

5 4 3 2 1

Have you?

7. How do you feel about the overall quality and service you are receiving here?

Doctor 5 4 3 2 1

Staff 5 4 3 2 1

Comments and/or Suggestions:

Your Name: (Optional but greatly appreciated)

Verification Code (case sensitive):

Thank you for sharing your comments with us!

Thank You For Helping Us To Help You!

If we are treating you well, we hope you will tell others. If we are not, we hope that you will tell us!

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