Patient Survey

We are constantly striving to provide better treatment and care for our patients. We would like to know how you perceive our services.
Please take a few minutes to complete this Patient Survey Questionnaire. Your responses are anonymous and will be used to better the office.
Your cooperation is greatly appreciated.


1. Please rate the appearance/impression of the following areas:

Waiting Room   54321

Reception Desk   54321

Treatment Rooms   54321

Consultation Room   54321

2. Please rate the appearance and professionalisim of our front desk team   54321

3. Please rate your observations as it pertains to our front desk team (specific team members will be helpful)

4. Please rate the appearance and professionalism of Dr. Simon's assistants   54321

5. Please relate your observations as it pertains to Dr. Simon's assistants (specific team members will be helpful)

6. Please relate your observations as it pertains to Dr. Simon   54321

7. Please rate the effectiveness of our appointment phone call reminder system   54321

8. Did you enjoy your experience at this website?   YesNo

9. Did you know that you could register online to gain access to your personal account information?   YesNo

10. How satisfied are you with the availability of appointment times?   54321

11. How do we rate with regards to keeping on time for your scheduled appointments?   54321

12. If you needed extra assistance with treatment (emergency appointment), how would you rate the response of Dr. Simon and/or Team?   54321N/A

13. How would you rate the way in which the treatment plan was explained to you?   54321

14. How satisfied were you with our policy on financial arrangements?   54321

15. Based on your experience, how likely are you to recommend our office to family or friends who need orthodontic treatment?   Would RecommendUnsureWould Not Recommend

16. Final Comments

aao
damon