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Patient Forms and Survey

Download and fill out our:
                    New Patient Form - PDF
                    Patient Survey - PDF

Patient Survey

Date of Visit:    Time of Visit:

Background Questions:

Please select the SERVICES YOU RECEIVED in the past 12 months.
Dental Hygiene
Fluoride Tx
Emergency Care
Teeth Whitening
Composite Filling
Porcelain Crowns
Porcelain Veneers
Root Canals
Tooth Extraction
Gum Treatment

Did you see the hygienist on every visit? Yes    No
Was your chief complaint addressed? Yes    No
Did someone review your medical history? Yes    No
Did you experience a relatively short waiting time? Yes    No
Were you educated about the types of services we offer? Yes    No
Were you in any discomfort during your treatment? Yes    No

Main source of Payment:
Self Pay     Private Insurance     Preferred Provider

Rate the following: Very
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

Are your human? Please type the answer to 2 + 2 = ? in Numerical form.

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