1122 E. Lincoln Ave. #208 • Orange, California • 92865 714-921-2110

Patient Survey

We need your input on how we can better serve you. Your feedback on this questionaire will tell us what you know about our practice. You do not need to put your name on the questionaire to ensure confidentiality.

When you telephoned to make an appointment, the staff members was courteous and helpful in finding a suitable time?

Excellent

Very Good

Average

Not so good

Terrible

Were you greeted in a friendly manner?

Excellent

Very Good

Average

Not so good

Terrible

Were you seated by your appointment time or advised of any delays?

Excellent

Very Good

Average

Not so good

Terrible

Did the dentist/hygienist take the time to listen to and understand your concerns?

Excellent

Very Good

Average

Not so good

Terrible

Did the dentist/hygienist take the time to adequately explain the treatment plan and answer your questions?

Excellent

Very Good

Average

Not so good

Terrible

Did you feel that you understood the prescribed treatment and all of your questions were answered to your satisfaction?

Excellent

Very Good

Average

Not so good

Terrible

Upon receiving your bill for the services redeemed was the amount clearly described?

Excellent

Very Good

Average

Not so good

Terrible

Upon receiving your bill for the services redeemed were payment options discussed?

Excellent

Very Good

Average

Not so good

Terrible

If you had a concern during your last visit, do you think it was properly handled by the staff?

Excellent

Very Good

Average

Not so good

Terrible

During your last visit, did you feel that the staff was concerned about your overall well being as a person and not just your dental condition?

Excellent

Very Good

Average

Not so good

Terrible

Are you comfortable with the level of technology used in the office?

Yes

No

Using the rating of 1 to 5, with 5 being the highest score how do you rate our office?

1

2

3

4

5

Are you aware that we are accepting new patients?

Yes

No

Is there anything you would like to change about your smile?

Yes

No

Would you be interested in a free cosmetic consultation with the doctor?

Yes

No

Would you like to refer a friend or family member to our office?

Yes

No

Suggestions for Improvement
We are always striving to improve our services. Your comments are important to us. How may we serve you better?

©2008 G. Mitchell Turk, D.D.S., M.A.G.D. • Site designed and maintained by TNT Dental.