Patients Survey

Thank you for choosing us for your dental care. We are always looking for ways to improve our services and other ways we can make you feel more comfortable. Please complete the following information selection the most appropriate answer based on your last visit.

Patient Name (optional):_______________________________________

E-mail Address (optional):______________________________________

What team member did you last see?______________________________

How would you rate your overall care?
      Excellent
      Very Good
      Average
      Not Good

When your appointment was over did you have a good understanding of your dental condition?
      Yes
      Not Really
      I wish I knew more

Were your financial options explained to you?
      Yes
      No
      I already understand my financial options

Did you have to wait past your appointment time to be seated? If so how long?
      1-5 min
      5-10 min
      10-15 min
      over 20 min

Did the staff greet you properly?
      Yes
      Not really
      I don’t recall

Would you refer your friends and family to Dr. Northen?
      Yes
      No
      I’m not sure

Please comment on anyone you met during your appointment, things we could change, new services you would like to have offered to you, or other ways we can make you feel more comfortable.

____________________________________________________________________

Please print and mail your survey or bring it with you to your next appointment. Thank you for your time and input.

© Copyright 2003-2006 Dental WebSmith, Inc. and Roger L. Northen, Jr., D.D.S., P.C. All rights reserved. Disclaimer: The information provided within is intended to help you better understand dental conditions and procedures. It is not meant to serve as delivery of medical or dental care. If you have specific questions or concerns, contact your health care provider.