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patient survey
Help Us Provide Better Service
Thank you for selecting us as your dental health care provider. We work hard to ensure our patients receive the best dental care while developing lasting relationships. Since all relationships benefit from honest communication, please take a moment to complete our patient survey. Your feedback will help us improve as individuals and lay the foundation to build the best dental practice possible.

Your Full Name (First & Last) - Optional:

(ex: John Doe)

 

Your Email Address (If Applicable) - Optional:

(ex: joedoe@email.com)

 

1.)

Overall, how would you rate the dental care you received?

            Neutral          
  Poor   1 2 3 4 5 * 6 7 8 9 10

Excellent

     
 

2.)

How would you rate the information communicated to you regarding your dental health?

            Neutral          
  Poor   1 2 3 4 5 * 6 7 8 9 10

Excellent

     
 
 

3.)

How would you rate the friendliness of our staff?

            Neutral          
  Poor  1 2 3 4 5 * 6 7 8 9 10

Excellent

     
 
 

4.)

How would you rate the competence of our staff?

            Neutral          
  Poor 1 2 3 4 5 * 6 7 8 9 10

Excellent

     
 
 

5.)

How would you rate the cleanliness of our office?

            Neutral          
  Poor 1 2 3 4 5 * 6 7 8 9 10

Excellent

     
 
 

6.)

Would you recommend a family member or friend to our office?

  Yes No
 
 

7.)

How were you referred to our office?

  Family    Friend    Print Ad    Internet    Other
 
 

Please let us know how we can improve our dental practice:

 
 

 

         

 

Online Form Security

To meet the security and privacy standards set by HIPAA, we utilize Secure Socket Layer (SSL) technology to secure this transmission. SSL is the industry standard security protocol. SSL creates a shared digital key, which only lets the sender and the receiver of the transmission scramble or unscramble information. To everyone else, the SSL transmission is indecipherable. This is the same level of security used by financial institutions and popular online retail outlets to secure sensitive data. Although no security process is 100% secure, we will continue to use the latest technologies available to ensure that our patient's private health information is protected to the fullest extent possible.

Most modern browsers will display an image of a closed lock or an unbroken key and a URL beginning with HTTPS indicating a secure session has been established.

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