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Hart Family Dentistry

Page One

1. Was this your first visit to our office? *This question is required.
2. How did you hear about us? *This question is required.
3. What was the purpose of your visit? *This question is required.
4. How likely is it that you would recommend our dental office to your family, co-workers, and friends? *This question is required.
Very likelyLikelyNeutralProbably NotNot Likely
5. How easy was it to set up your appointment? *This question is required.
Very EasyEasyNeutralDifficultVery Difficult
6. How were you greeted when you arrived? *This question is required.
7. How clean/neat was the waiting area? *This question is required.
8. How acceptable was the length of time you had to wait before you were taken back and seated? *This question is required.
Very DissatisfiedDissatisfiedNeutralSatisfiedVery Satisfied
9. How clean/neat was your patient room? *This question is required.
10. To what degree were your concerns addressed/answered by either the dental assistant, hygienist, or the dentist? *This question is required.
Not Satisfied
Neutral
Very Pleased
11. Rate how at ease you felt with your hygienist:
Very uncomfortableUncomfortableNeutralComfortableVery Comfortable
12. If applicable, how would you rate the quality of service performed by your hygienist?
Poor
Neutral
Excellent
13. How would you rate the quality of service performed by the assistant and/or dentist? *This question is required.
Poor
Neutral
Excellent
14. How would you rate the friendliness of our staff? *This question is required.
Not Friendly
Neutral
Very Friendly
15. How would you rate the friendliness of the dentist? *This question is required.
Not Friendly
Neutral
Very Friendly
16. How would you rate checking out and paying after the appointment? *This question is required.
Very DifficultDifficultNeutralEasyVery Easy
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