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 Celeste 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 (on the back).
Appointments |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
Not Applicable |
I am satisfied with the process for making an appointment. |
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The appointment secretary was courteous and helpful. |
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Staff |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
Not Applicable |
The dentist was professional and courteous. |
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The dental hygienist was professional and courteous. |
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The dental assistant was professional and courteous. |
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The staff was considerate and sensitive to my needs. |
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Treatment |
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
Not Applicable |
The proposed treatment was clearly explained to me and alternatives were given. |
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All my questions were answered. |
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The dental treatment was completed in a timely and efficient manner. |
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The dental staff ensured I was comfortable throughout the procedure. |
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I am pleased with the quality of dental treatment. |
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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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Patient Satisfaction Survey |
| Author | mhollister |
| File Modified | 0000-00-00 |
| File Created | 2022-01-14 |