Patient Survey

Your Opinion Matters!

We appreciate you taking the time to complete our survey. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.

Patient name

E-mail address

1. What motivated you to go to the dentist the last time you were there?

2. When was the last time you went to the dentist?

3. What prevents you from going to the dentist regularly?

4. What would be your top sources to find a dentist?
Direct Mail (Newsletters, Postcards, Letters)
Coupons
Directories (Yellow Pages)
TV
Radio
Newspaper
Magazine
Internet Search Engine
Referral from family or friends
Referral from a Dentist or Physician

5. Rate the following in terms of importance in choosing a dentist.

	Least Important	Most Important
Cost	1 2 3 4 5 6 7 8 9 10

Reputation	1 2 3 4 5 6 7 8 9 10

Knowledge/Training	1 2 3 4 5 6 7 8 9 10

Uses Latest Technology	1 2 3 4 5 6 7 8 9 10

Takes My Insurance	1 2 3 4 5 6 7 8 9 10

Location	1 2 3 4 5 6 7 8 9 10

Convenient Hours	1 2 3 4 5 6 7 8 9 10

Good Customer Service	1 2 3 4 5 6 7 8 9 10

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