Dental Patient Feedback Form

Collects patient impressions after a dental visit so a clinic can spot what's working and what needs improvement.

Use this template

Name

First Name

Last Name

Date of visit

Dentist/Provider

Clinic Location

Street Address

City

State / Province

ZIP / Postal Code

Was your appointment scheduled promptly and conveniently?

Yes No

If no, please specify any issues or concerns

Did you receive a reminder notification before your appointment?

Yes No

If yes, how did you receive the reminder?

Phone call Text message Email Other

Were your insurance and payment questions addressed to your satisfaction?

Yes No

If no, please specify any issues or concerns

Were you seen by your dentist/provider in a timely manner?

Yes No

If no, please specify any delays experienced

Were your treatment preferences and concerns addressed during the appointment?

Yes No

If no, please specify any unaddressed concerns

Were you satisfied with the overall ambiance and atmosphere of the clinic?

Yes No

If no, please specify any areas for improvement

Based on your visit today, would you recommend our dental clinic to friends or family?

Yes No

If no, please specify any reasons for not recommending

Please share any additional comments, suggestions, or feedback about your experience at our dental clinic.

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