SECTION 1 - BEFORE AND ON ARRIVAL

1. How did you hear about the practice?

2. Reception

a) Did you receive a reminder about your appointment?
YesNoDon't Know

b) Would you prefer to receive reminders by:
TextEmailNot at all

c) Are the reception staff helpful?
YesNo

d) Have you ever been kept waiting too long to see the dentist/hygienist?
YesNo

e) Are there any other times that you would like to see the surgery to be open? If Yes, when.


SECTION 2 - YOUR APPOINTMENT

3. Are you a Denplan patient or Private patient?

4. Who did you see?

5. Did you require...

6. Thinking about your appointment with the dentist/hygienist today, how do you rate the following?

a) How well the dentist/hygienist listened to what you had to say?
Very poorPoorFairGoodVery GoodExcellent

b) How well the dentist/hygienist put you at ease during your treatment?
Very poorPoorFairGoodVery GoodExcellent

c) How much the dentist/hygienist involved your decision about your care?
Very poorPoorFairGoodVery GoodExcellent

d) How well the dentist/hygienist explained your problems or any treatment you needed?
Very poorPoorFairGoodVery GoodExcellent


SECTION 3 - YOUR TREATMENT

1. If you needed treatment that involved more than a cleaning were you given:

a) A written treatment plan?
YesNo

b) Details about the cost?
YesNo

c) An idea of how long treatment would take?
YesNo

2. How likely are you to recommend our dental practice to friends and family if they need similar care or treatment?
Extremely likelyLikelyNeither likely or unlikelyExtremely unlikelyDon't know

Thinking about this response, what is the main reason for feeling this way?

Thank you for your time to help us with your feedback - Your response is confidential.