Survey

Patient name

E-mail address

Was this your first visit to our office, or have you been here before?
First Visit
Been Here Before

If you answered “first visit,” how did you hear about us?
Someone referred me. Name (optional)
American Academy of Cosmetic Dentistry Web site
Office Web site: www.stevanorserdds.com
Magazine Ad: Magazine
Direct Mail
Internet Search
Other (please specify):

What service(s) did we provide?
Consultation
Exam
Cleaning
Smile Whitening
Filling
Bonding or Veneer
Crown or Bridge
Dental Implant

In addition to offering the latest treatment options, we at Arlington Adult Dentistry strive to provide the utmost in service and patient care.  To accomplish this, we need your input.  Your input will help us maintain the highest possible standards in our Dental Practice.

Please rate our office and staff on each of the following:

Greeting (friendly and welcoming) by our front office staff:
Excellent
Very Good
Good
Fair
Poor
Comments:

Office environment (cleanliness, comfort, temperature, location):
Excellent
Very Good
Good
Fair
Poor
Comments:

How long did you wait before being seated in a room?
0 Minutes/No Wait
15 to 30 minutes
30 to 45 minutes
Over 45 minutes
Comments:

Friendliness and professionalism of the clinical team:
Excellent
Very Good
Good
Fair
Poor
Comments:

Friendliness and professionalism of Dr. Orser:
Excellent
Very Good
Good
Fair
Poor
Comments:

Did Dr. Orser listen to you and answer your questions?
Definitely Yes
Mostly Yes
Not Sure
Mostly Not
Definitely Not
Comments:

Do you feel that Dr. Orser spent the appropriate amount of time with you?
Definitely Yes
Mostly Yes
Not Sure
Mostly Not
Definitely Not
Comments:

When your appointment was over, did you have a good understanding of your dental situation and treatment options?
Definitely Yes
Mostly Yes
Not Sure
Mostly Not
Definitely Not
Comments:

Were your financial options explained to you?
Yes
No
Does Not Apply
Comments:

How would you rate your overall visit?
Excellent
Very Good
Good
Fair
Poor
Comments:

Would you refer your friends and family to us?
Definitely Yes
Mostly Yes
Not Sure
Mostly Not
Definitely Not
Comments:

Please comment below on how we could make your next visit better and more comfortable.

Thank you for completing our Patient Experience Survey.  Your concerns and suggestions are important to us.