On
a one-to-five scale, with 1: terrible, 2: poor,
3: okay, 4: very good and
1
2
3
4
5
1.
How would you rate the care you receive from
your dentist and his/her staff?
2.
More specifically, how would you rate each
of the following:
a. Dentist
b. Dental Hygienist
c. Receptionist
d. Dental Assistant/Chair side staff
e. Administrative Staff
3.
The cleanliness of the office
4.
Office operations
5.
The atmosphere of the office
6.
The office décor
7.
From your experience, how would you rate the
technical skills of your dentist?
On
a one-to-five scale, with 1: strongly disagree,
2: disagree, 3: neutral or undecided,
1
2
3
4
5
8.
The dentist and the staff attending me always
put on fresh, sterile gloves before treating me.
9.
I appreciate the dental staff reminding me
of check-up times.
10.
My dentist cares about me as a person.
11.
My dentist and the staff make me want to have
the best oral health possible.
12.
I am confident that my dentist practices all
of the proper sterilization procedures
13.
My dentist is never too busy to answer any
questions I have.
14.
My dentist keeps current with the latest dental
procedures.
15.
The doctor and staff are considerate of my
feelings.
16.
I always feel better about myself after I have
visited this dentist
17.
I know what my doctor expects me to do to improve
my oral health
18.
My dentist gives me a thorough examination before
he/she does any treatment.
19.
For my last visit to the dental office, the
doctor or staff member was ready for me at the
appointed time.
20.
My dentist has helped me understand that I can
keep my natural teeth for a lifetime.
21.
It has been easy for me to get appointments
to see my dentist.
22.
I believe this dental practice is the best available
for the treatment I need.
23.
My dentist asks for my opinions about the treatment
program.
24.
My dentist is my friend.
25.
My dentist seems to be excited when he/she
sees any improvement in my oral health.
26.
My dentist knows a lot about me as an individual.
27.
My dentist has helped me learn that I am in
control of my health.
28.
I do not expect to have any teeth (excluding
wisdom teeth) extracted during the rest of my
life.
29.
There is at least one person on the staff of
this office whom I feel is a close friend.
30.
Has your dentist referred you to a specialist?
a. If so, did the specialist have complimentary
things to say about your dentist?
Yes
No
b. Did the specialist provide you high quality
care?
Yes
No
31.
What do you like best about this dental office?
32.
Please write any comments here that you feel
will be helpful in providing better service to
you and others.
33.
Enter Code as shown in the box:
