Form 0917-0036-34 0917-0036-34, Dental Patient Satisfaction Survey

Form Approved

OMB Form No. 0917-0036-34

Expiration Date: 5/31/2015

White Earth Dental Clinic Patient Satisfaction Survey

Provider: Imler Mork Vu Dyda Bruce Kari P. Jeri S.

Dental Assistant: _________________

Receptionist: _________________

We would like to know how you feel about your dental care. Your comments will be held in strict confidence. Your survey results will be shared with clinic administration and dental staff in the interest of improving patient care. Please add any comments you feel are important.

Please complete the following items for the Dental Patient

 Myself  My child  Other family member  Designated Adult

Patient’s age:

 0-5  6-12  13-18  19-40  41-65  over 65

Number of visits the patient has made to the dental office in the past 12 months:

1  2  3  4 5 or more Not Sure

What treatment was provided today (circle all that apply):

extraction root canal exam cleaning filling(s)

denture/partial appt.  stainless steel crown sealants 

other ________________

Please Check Each Item:

Appointments	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Not Applicable
If the staff was unable to make a follow-up appointment today, they explained how and when to contact the clinic to make one in the near future.
The appointment secretary was courteous and helpful.
Any questions regarding appointment policies were clearly answered and explained by staff.
Staff	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Not Applicable
The dentist was professional and courteous.
The dental hygienist was professional and courteous.
The dental assistant was professional and courteous.
The staff was considerate and sensitive to my needs.
Treatment	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	Not Applicable
The proposed treatment was clearly explained to me.
All my questions were answered.
Treatment alternatives were given.
The dental treatment was completed in a timely and efficient manner.
The dental staff ensured I was comfortable throughout the procedure and if discomfort was experienced, took appropriate measures to help relieve it.
I am pleased with the quality of dental treatment.

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for taking the time to complete this survey. Please place it in the suggestion box on your way out of the Dental Dept.