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Client satisfaction survey

Name: Date of service:     
Email: 
At Phenix Dental Clinic, we strive to exceed your expectations by treating you respectfully while providing quality, evidence-based dentistry. We request that you take a moment to complete this questionnaire. We thank you in advance for your help.
  Scheduling and Telephone Experience Excellent Good Fair Poor N/A
1 Efficiency of scheduler in gathering info
2 Promptness of return calls (if applicable)
3 Helpful and polite scheduler
4 Overall ease of scheduling
  Waiting Room Experience Excellent Good Fair Poor N/A
5 Warm greeting upon arrival
6 Speed of check-in process
7 Waiting time
8 Overall satisfaction with the waiting room experience
  Experience with Dental Hygienist Excellent Good Fair Poor N/A
9 Friendly and courteous hygienist
10 Appeared professional and technically competent
11 Provided clear instructions
12 Overall satisfaction with your hygienist
  Experience with Dentist Excellent Good Fair Poor N/A
13 Showed general concern for your well-being
14 Explanation of findings and treatment plan
15 Encouraged and answered your questions
16 Spent an adequate amount of time with you
17 Overall satisfaction with Dentist
  Billing Excellent Good Fair Poor N/A
18 Timely receipt of final bill
19 Explanation of findings and treatment plan
20 Encouraged and answered your questions
21 Spent an adequate amount of time with you
  Overall Satisfaction Excellent Good Fair Poor N/A
22 Cleanliness of facilities
23 Friendly and knowledgeable staff
24 Quality of service
  Yes   No
25 Would you recommend Phenix Dental Clinic to others?  
Is there an employee you would like to acknowledge for the service you received?
Why?  
Would you like to be contacted by our Office Manager regarding this survey?          
Additional Comments/Suggestions: