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1st Visit |
Repeat patient (skip to #3) |
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Was this your first visit to our office or have you been here before? |
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| 3. |
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What was the purpose of your visit? |
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| On a scale of 1 to 5, with 5 being "Great," how would you rate your experience on your last visit? If a particular line does not apply to your visit, please skip it. |
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| On a scale of 1 to 5, with 5 being "Great," how would you rate your experience on your last visit? If a particular line does not apply to your visit, please skip it. |
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Poor |
Fair |
Okay |
Good |
Great |
| 5. |
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Ease of setting your appointment |
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Greeting by our receptionist when you arrived |
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Cleanliness/neatness of the waiting room |
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Cleanliness/neatness of the operatory |
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Length of time you had to wait before you were called for your appointment |
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Friendliness of our office staff |
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Friendliness of the dentist |
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| 12. |
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Quality of the service performed |
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Degree to which your concerns were addressed by either the technician or the dentist |
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The ease of checking out and paying after the appointment |
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In your own words, let us know any issues or concerns you may have about our services or office practices and procedures. |
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Poor |
Fair |
Okay |
Good |
Great |
| 16. |
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How likely is it that you would recommend our dental office to your family members, co-workers, and friends? |
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| If you would like to provide us with your contact information please use the boxes below: |
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| If you would like to provide us with your contact information please use the boxes below: |
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