Casey Dentists Online Survey

First Name*

Last Name*

Phone*

Email*

1. Was this your first visit to Casey Dentists? 1. Was this your first visit to Casey Dentists? New Existing

2. Please choose your gender 2. Please choose your gender Male Female

3. Which provider did you see? 3. Which provider did you see? Dr Casey Dr Cullen Dr Dashan Hygienist Marney

4. Do you find Front Office staff are pleasant and helpful on the phone? 4. Do you find Front Office staff are pleasant and helpful on the phone? Yes No Sometimes

5. Were you seen by the provider on time 5. Were you seen by the provider on time On Time 5mins late 10mins late 15mins late 20mins late Over 20mins late

6. How well did you feel the Dentist/Hygienist and team worked together? 6. How well did you feel the Dentist/Hygienist and team worked together? Perfect Good Normal Poor Terrible

7. Was your presenting dental problem addressed by the dentist / hygienist in a manner that you were comfortable with? 7. Was your presenting dental problem addressed by the dentist / hygienist in a manner that you were comfortable with? Yes No

8. How clearly did the Dentist/Hygienist explain any treatment options to you? 8. How clearly did the Dentist/Hygienist explain any treatment options to you? Perfect Good Normal Poor Terrible

9. How would you rate this practice overall for cleanliness and tidiness of appearance? 9. How would you rate this practice overall for cleanliness and tidiness of appearance? Perfect Good Normal Poor Terrible

10. Would you refer your family and friends? 10. Would you refer your family and friends? Strongly Agree Agree Unsure Disagree Strongly Disagree

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