Comment Form

1. Were you greeted with a smile when you came in?

   Yes No

2. Does the office provide a welcome, comfortable and clean environment?

   Yes No

3. Did you have to wait longer than 15 minutes for your appointment?

   Yes No

4. Did your assistant tell you how long your appointment would be today?

   Yes No

5. Did your appointment last longer than what your assistant said it would?

   Yes No

6. Was your assistant friendly?

   Yes No

7. Was your assistant gentle?

   Yes No

8. Were you given an oral hygiene grade?

   Yes No

9. Did your assistant meet with you to discuss treatment?

   Yes No

10. Were you asked if you had any questions for Dr. Green?

    Yes No

11. Do you feel informed about your treatment at our office?

    Yes No

12. Were you given a receipt upon payment?

    Yes No

13. If you had any account problems, were they taken care of professionally and promptly?

    Yes No

14. Was your visit a pleasant experience?

    Yes No

15. Were the doctor and staff friendly and courteous?

    Yes No

16. Were your questions answered fully?

    Yes No

17. Parents ONLY - Do you like the oral hygiene grading system?

    Yes No

18. How satisfied were you with the way you were treated by the doctor?

    Very Satisfied
    Somewhat Satisfied
    Undecided
    Dissatisfied






19. How satisfied were you with the way you were treated by the staff?

    Very Satisfied
    Somewhat Satisfied
    Undecided
    Dissatisfied






20. What did you like most, if anything, about your visit to our office?

    Comments:

21. What did you like least, if anything, about your visit?

    Comments:

22. Please tell us what, if anything, we can do to make future visits to our office more enjoyable for you.

    Comments:

23. Any further comments would be greatly appreciated.

    Comments:

Thank you for sharing your comments with us!