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1st Visit
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Repeat patient (skip to #3)
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1.
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Was this your first visit to our office or have you been here before?
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2.
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If you answered "1st Visit," how did you hear about us?
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Other:
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3.
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What was the purpose of your visit?
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On a scale of 1 to 5, with 5 being "Great," how would you rate your experience on your last visit? If a particular line does not apply to your visit, please skip it.
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Poor
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Fair
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Okay
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Good
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Great
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4.
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Ease of setting your appointment
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5.
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Greeting by our receptionist when you arrived
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6.
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Cleanliness/neatness of the waiting room
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7.
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Cleanliness/neatness of the operatory
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8.
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Length of time you had to wait before you were called for your appointment
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9.
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Friendliness of our office staff
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10.
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Friendliness of the dentist
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11.
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Quality of the service performed
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12.
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Degree to which your concerns were addressed by either the technician or the dentist
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13.
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The ease of checking out and paying after the appointment
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14.
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In your own words, let us know any issues or concerns you may have about our services or office practices and procedures.
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Poor
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Fair
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Okay
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Good
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Great
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15.
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How likely is it that you would recommend our dental office to your family members, co-workers, and friends?
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If you would like to provide us with your contact information please use the boxes below:
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