| How did you hear about us? |
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| Date of last visit: |
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| Did you have an appointment? |
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| Did you find our working hours convenient for you? |
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| Did you find our parking convenient? |
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| Upon entering our clinic, were you properly greeted and acknowledged by our staff? |
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| Did the waiting area look clean and orderly? |
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| How long did you wait before being seen by the dentist? |
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| Was the receptionist helpful, polite and pleasant? |
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| Was the dental assistant(s) friendly, supportive and confident? |
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| Was the dentist who attended you confident and focused? |
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| Did the dentist explain your treatment, answer your questions and listen to your concerns? |
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| Did the procedure room seem clean and hygienic? |
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| The level of dental treatment I received was: |
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| How would you rate the overall quality of service you received at Fox Family Dental? |
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| Would you recommend us to your family, friends and co-workers? |
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| Additional Comments or Suggestions: |
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| If this is a complaint, do you wish to be contacted for follow-up? |
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| The following information is optional, but is required if you wish to be contacted: |
Name
First Name Required |
Email Address
Email Required |
Day Phone
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Evening Phone
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