General Questions

How did you enjoy your visit?

What would you have liked to change about your visit?

Did your dentist address your primary concerns? (please explain)

Was your visit pain-free and comfortable?
yes     no

Was your visit rushed?
yes     no

Would you refer your family and friends to Greenfield Dental Associates?
yes     no

Please rate the following on a scale of 1 through 5:
(1 = poor   5 = excellent)

The Office

Parking
1      2      3      4      5      NA

Furniture:
1      2      3      4      5      NA

Walls:
1      2      3      4      5      NA

Lighting:
1      2      3      4      5      NA

Size of office:
1      2      3      4      5      NA

Restrooms:
1      2      3      4      5      NA

Office Staff

Friendliness:
1      2      3      4      5      NA

Intelligence:
1      2      3      4      5      NA

Cared about your problem:
1      2      3      4      5      NA

Promptness:
1      2      3      4      5      NA

Personal Appearance:
1      2      3      4      5      NA

Operatory

Color:
1      2      3      4      5      NA

Decor:
1      2      3      4      5      NA

Scent:
1      2      3      4      5      NA

Dental Chair:
1      2      3      4      5      NA

Lighting:
1      2      3      4      5      NA

Noise:
1      2      3      4      5      NA

Equipment:
1      2      3      4      5      NA

Cleaniness:
1      2      3      4      5      NA

Your Dentist

Friendliness:
1      2      3      4      5      NA

Intelligence:
1      2      3      4      5      NA

Cared about your problem:
1      2      3      4      5      NA

Promptness:
1      2      3      4      5      NA

Personal Appearance:
1      2      3      4      5      NA

Dental Assistant

Friendliness:
1      2      3      4      5      NA

Intelligence:
1      2      3      4      5      NA

Cared about your problem:
1      2      3      4      5      NA

Promptness:
1      2      3      4      5      NA

Personal Appearance:
1      2      3      4      5      NA

Hygienist

Friendliness:
1      2      3      4      5      NA

Intelligence:
1      2      3      4      5      NA

Cared about your problem:
1      2      3      4      5      NA

Promptness:
1      2      3      4      5      NA

Personal Appearance:
1      2      3      4      5      NA

Your Experience

Understood treatment:
1      2      3      4      5      NA

Comfort during treatment:
1      2      3      4      5      NA

Your Bill

Knew cost before treatment:
1      2      3      4      5      NA

Payment terms understood:
1      2      3      4      5      NA

Additional Comments