Patient Name (optional)

E-mail address (optional)

Who were you here to visit today?
Dr. Anderson Jennifer

How would you rate your overall visit?
Excellent Very Good Average Not so good

Was it easy for you to make an appointment?
Yes No I don't recall

When your appointment was over did you have a good understanding of your dental situation?
Yes Not really I wish I knew more

Were your financial options explained to you?
Yes No I already understand my financial options

Did you have to wait past your appointment time to be seated? If so how long?
No 5 to 10 minutes 10 to 20 minutes Over 20 minutes

Was the reception area welcoming?
Yes No I don't recall

Did the staff greet you properly?
Yes Not really I don't recall

Were you treated professionally during your visit?
Yes Not really I don't recall

Would you refer your friends and family to Dr. Anderson?
Yes No I'm not sure

Please comment on anyone you met during your visit, things we could change, new services you would like to see, or other ways we can make you feel more comfortable?