Please take a moment to fill out the following questionnaire. Completed forms will be entered monthly for a $100 Gas card drawing. We appreciate your time and comments as we strive to continually improve our services.
Was this the first time you visited this office? Yes No
Why did you choose our office? Or How did you hear of our office?
12345678910 How would you rate your overall experience with our profession?
12345678910 What is the likelihood you would return to this professional?
12345678910 How likely are you to recommend this professional to your family and friends?
12345678910 Did the professional spend enough time with you during the visit?
12345678910 Did the professional listen to your questions carefully?
12345678910 Did the professional answer your questions thoroughly and properly?
12345678910 What is the degree of trust you have in this professional?
If applicable, did you receive clear printed or written information? Yes No
12345678910 How easy was it to schedule a visit?
12345678910 How appealing was the office in general?
12345678910 How would you rate the parking experience?
12345678910 How would you rate the front office staff friendliness?
12345678910 How would you rate the clinical staff effectiveness?
12345678910 How would you rate the clinical staff behavior when the doctor was not present?
How many minutes (approximately) did you spend with the dental professional during this visit?
Please enter any additional comments you would like to share with this office (remember that your responses are anonymous unless you mention your name.)
(Optional and used only for the purpose of notifying the prize drawing winner):
I would like the Practice Administrator to contact me regarding my experience with Three Rivers Dental?
