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Patient Survey

Patient Name:


How would you rate your overall visit?
Very Satisfied   Satisfied   Somewhat Satisfied

Did the staff treat you professionally on the phone?
Yes   No   I don't recall

Did the staff greet you properly?
Yes   No
Comments

Were the assistants and hygienists friendly and professional to you and your child?
Yes   No
Comments

Was the doctor professional and courteous to you and your child?
Yes   No
Comments

Did cleanliness of our practice meet your expectations?
Yes   No

Were your financial matters handled in a timely and well addressed manner?
Yes   No

Would you refer your friends and family to us?
Yes   No
Please comment on how we could make your visit better.

Please type "123" in the box below to complete submission:

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