Gender
Male
Female
Age Group
0 - 18
19 - 24
25 - 34
35 - 44
45 - 54
55 - 64
64+
Reason for your visit?
Routine Exam
Dental Emergency
How long did you wait for this appointment?
Same day
1 - 3 days
4 - 6 days
7+ days
Was this your first visit to The Dental Centre?
Yes, I am a new patient
No, I am a regular patient of the practice
Was the receptionist helpful when booking the appointment?
Yes
No
Can't remember
On arrival for your appointment did the receptionist acknowledge you in a polite and courteous manner?
Yes
No
Can't remember
Do you feel that reception staff respect your need for confidentiality and privacy?
Yes
No
Unsure
Were you given the information you needed following your dental appointment e.g costs of treatment, payments, next appointment booking?
Yes
No
Unsure
Overall, on a scale of 1-10 ( 1 being lowest and 10 being highest) how satisfied are you with our reception services?
Your treatment:
Were you able to discuss your needs & concerns with your dentist?
Yes
No
Did you find the assisting nurse professional and friendly?
Yes
No
Were you given a full and clear explanation of the treatment needed?
Were the charges for your treatment clearly explained by the dentist/reception staff?
Yes
No
Not relevant
Were you given a treatment plan?
Yes
No
Can't remember
Overall, on a scale of 1-10 ( 1 being lowest and 10 being highest) how satisfied were you with your treatment during the visit ?
Waiting Room Literature:
Do you access the patient leaflets on offer in the waiting room?
Yes
No
Haven't Noticed
Do you feel the leaflets cover all subjects of interest to you?
Yes
No
No opinion
Please give us any suggestions you may have for patient information you feel may be helpful?
Are you happy with the methods used by the practice to contact you E.g letters/texts?
Yes
No
No opinion
How would you prefer to be contacted about your next appointment?
Text message
Email
Overall, on a scale of 1-10 ( 1 being lowest and 10 being highest) how do you rate the practice website?
Did you visit our facebook page?
Yes
No
Do not use Facebook
Please feel free to make any suggestions on area of the practice
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