248.647.5434 50 West Big Beaver, Ste. 280   Bloomfield Hills, MI 48304

Patient Survey

Your opinion matters to us.

Patient Satisfaction Questionnaire

We would like to know your experiences during your last visit to our office. Please complete the questionnaire below and then send the form back to our office in the enclosed envelope. We strive to make every visit pleasurable and your feedback is crucial to us achieving this goal.

Please rate the following categories with 1 indicating dissatisfaction and 5 indicating very satisfied.

 

Were you seated and seen in a timely fashion?

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Now that you have completed your restorative dental work, how would you rate your overall experience?

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How friendly, understanding, and warm did you find the scheduling coordinator when making your initial appointment?

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How pleased were you with your dental assistant's performance and communication skills during your visit?

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How would your rate your overall initial visit with our office?

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How would you rate our administrative team's customer service?

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How satisfied were you with your hygienist and the dental cleaning performed?

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How would you rate our telephone customer service?

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How well did Dr. «Last_Name» explain your treatment needs?

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How would you rate our explanation of patient financial obligations and responsibilities?

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How would you rate our office's appearance and cleanliness?

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How willing would you be to refer others based on your first experience with our office?

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How fair do you feel our financial policies are?

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Please let us know anything else you would like to tell us in the space below!
©2009 Dr. David G. Banda | Site designed and maintained by TNT Dental