Patient Forms and Survey | Dental Expressions

Date of Visit:*

Time of Visit:*

Background Questions:

Please select the SERVICES YOU RECEIVED in the past 12 months.

Did you see the hygienist on every visit?*

Was your chief complaint addressed?*

Did someone review your medical history?*

Did you experience a relatively short waiting time?*

Were you educated about the types of services we offer?*

Were you in any discomfort during your treatment?*

Main source of Payment:*

Rate the following:

1. Comfort of the Reception Area*

2. Cleanliness of the Dental Practice*

3. Dental Equipment and Technology*

4. Receptionist's concern for your needs*

5. Friendliness of the Dental Assistant*

6. Hygienist attentive to your needs*

7. Your chief concerns addressed by your doctor*

8. Treatment plan options provided to suit your needs*

9. Variety of payment options presented*

10. Likelihood to share your positive experiences with friends / family*

11. Thoroughness in the examination*

12. Accessibility of obtaining appointment from time of initial call*

13. Ease with which you were able to schedule an appointment*

14. Availability of dental practice hours*

15. Appointment timeliness*

16. Dental team working well together to create positive experience for you and your family*

17. Overall rating of dental care provided*

18. Education provided by hygienist on oral health*

19. Professionalism of the hygienist*

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