1. How were you referred to our office?
 Friend        Dentist        Website        Other

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2. Were you able to schedule an appointment at a time convenient for you?
 Yes       NO

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3. Did you have to wait over 15 minutes past your appointment time to be seated? If so how long?
 NO        15 to 30 minutes        30 to 45 minutes        Over 45 minutes

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4. Did our staff make you feel comfortable and relaxed?
 Yes        NO

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5. When your appointment was over did you have a good understanding of your dental situation?
 Yes        NO

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6. Was the explanation of financial options explained to your satisfaction?
 Yes        NO

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8. Would you recommend this office to a friend, relative or colleague?
 Yes        NO

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Please comment on how we could make your visit better, new services you would like to see, or other ways we can make you feel more comfortable.

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