Please take a moment to answer the survey. Your feedback will greatly help us in implementing improvements in our customer care standards. The result of this survey will remain confidential and the completed form will only be used internally for the purpose of serving you better. Thank you for your time.
B1. Did you like the atmosphere and/or decor of our office? Yes No
B2. Was there any aspect of our facility that you were particularly satisfied with? Yes No
B3. Was there any aspect of our facility that you were unsatisfied with? Yes No
Please give your comments on how we can further improve this aspect of our practice.
C1. Did we make you feel welcome when you came into our office? Yes No
C2. Did we serve you in a friendly manner when you had questions? Yes No
C3. Was there a staff member that was particularly helpful to you during your visit? Yes No
C4. Was there a particular staff member that needs to improve some aspects of his/her service? Yes No
If yes, please tell us about him/her and how she can improve his/her service.
D1. Did we remind you of your appointment a few days ahead? Yes No
D2. Did you have to wait a long time past your appointment time to be seated? Yes No
D3. If you did, for how long? 15 to 30 minutes 30 to 45 minutes over 45 minutes
Please give your comments on how we can further improve this aspect of our service.
E1. Did we give you a thorough understanding of the financial options available to you? Yes No
E2. Were your financial matters handled in a timely and satisfactory manner? Yes No
If no, please give suggestions on how we can further improve this aspect of our service.
F1. What type of services did you request from our office?
F2. Did we discuss with you all available treatment options during your consultation? Yes No
F3. Did we discuss with you the details of the procedure prior to your treatment? Yes No
F4. Did you encounter any problem, or do you have any complaints regarding your treatment? Yes No
If yes, please tell us about it.
G1. What other information would you like to be made available to you during your visit to our office and/or on our website? Please list them down or write down a topic that is relevant for you to learn about. (Example: Infection control, pain management, etc.)
G2. How did you learn about our practice and services?
G3. Would you recommend our office to your family and friends? Yes No
