Patient Feedback Survey

How did you hear about us?
 Family/Friend/Co-worker
 Radio
 Newspaper
 Website
 Phonebook
 Other

If Other (please specify)


Who were you here to visit on your most recent trip to our office?
 Dr. Jim S. Caudill
 Becki
 Valarie

Did we greet you properly, make you feel welcome and serve you in a friendly manner?
 Yes
 No
 Not really
 I don't recall

Did you have to wait over 15 minutes past your appointment time to be seated? If so, how long?
 No
 15-30 minutes
 31-45 minutes
 Over 45 minutes

Were your billing questions and financial options adequately explained to you?
 Yes
 No
 I already understand my financial options
Did you have any questions that were not completely resolved before leaving our office?
 Yes
 No

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

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

Would you refer your friends and family to our office?
 Yes
 No
 I am not sure

How would you evaluate the cleanliness of our office?
 Excellent
 Good
 Fair
 Poor

Please comment on things we could change, new services you would like to see or other ways we can improve future visits or make you feel more comfortable:


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