Practice Survey

Dear Patient and/or Parent,

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.

Which is your primary office?

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

Please use the following scale for your responses:
5. Very Good    4. Good    3. Average    2. Poor    1. Very Poor
  Comments
Waiting room 5 4 3 2 1    
Reception desk 5 4 3 2 1
Treatment rooms 5 4 3 2 1
Consultation room 5 4 3 2 1
 

Please feel free to list specific staff names.
2. Please rate the appearance and professionalism of our front desk staff

5  4 3 2 1

 
3. Please rate your observations as it pertains to our front desk staff (specific staff names will be helpful)
 
4. Please rate the appearance and professionalism of our orthodontic assistants

5  4 3 2 1

 
5. Please relate your observations as it pertains to our orthodontic assistants (specific staff names will be helpful)
 
6. Please relate your observations as it pertains to our orthodontists
5  4 3 2 1| Comments:
 
7. Please rate the effectiveness of our appointment phone call reminder system

5  4 3 2 1 | Comments:

 
8. Have you visited our website at www.orthodontists.com?    
YES NO
 
9. Did you know that you could register online to gain access to your personal account information?
YES NO
 
10. How satisfied are you with the availability of appointment times?

5  4 3 2 1 | Comments:

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

5  4 3 2 1 | Comments:

 
12. If you needed extra assistance with treatment (emergency appointment), how would you rate the response of the Doctor and/or Staff? 
5  4 3 2 1 N/A | Comments:
 
13. How would you rate the way in which the treatment plan was explained to you?
5  4 3 2 1 | Comments:
 
14. How satisfied were you with our policy on financial arrangements?
5  4 3 2 1 | Comments:
 

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

 

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Thank you for your time.

Sincerely,
Adam J. Weiss, D.M.D., May Nooreyazdan, D.M.D. and Staff