Dental Patient Experience Survey

Ask patients about their visit history, how the staff made them feel, and how likely they are to recommend the practice.

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Have you visited our oral care center?

Yes No

How did you hear of us?

Referral Online search Social media Other

Please Specify

How many times have you visited us previously?

First time 2 to 5 times More than 5 times

How long have you been a regular patient with us?

Less than a year 1 to 3 years More than 3 years

How often do you visit the dentist?

Every 6 months Once a year Only when needed

Please specify

What is the name of the dentist who treated you?

First Name

Last Name

How satisfied are you with the dentist's attitude and behavior?

★ 1 star ★ 2 stars ★ 3 stars ★ 4 stars ★ 5 stars

In which areas does our staff make you comfortable?

Friendliness Clear communication Wait times Cleanliness

Please specify

Would you recommend your friends and family have their dental work done with us?

Yes No

Please specify

Is there anything else we could do to improve your dental experience?

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