Name


Email

1) How did you first hear about us?
Website
Friend or Family Member
Brochure Received in Mail
My Insurance
Other (please specify)

2) How would you rate your overall visit?
Excellent
Very Good
Average
Not So Good

3) When your appointment was over did you have a good understanding of your dental situation?
Yes
Not Really
I Wish I Knew More About My Situation

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

5) 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

6) Did the staff greet you properly?
Yes
Not Really
I don't recall

7) Would you refer your friends and family to us?
Yes
No
I'm Not Sure

8) If you would like to be entered to win a free Whitening Kit, please answer this questions with your name and e-mail address or phone number along with any questions or comments you may have. Good luck!