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Patient Survey
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Name (Optional)
First
Last
Email (Optional)
Was this your first visit to our office?
Yes
No
What was the purpose of your visit today?
New Patient Evaluation
Periodontal Surgery
Implant Surgery
Periodontal Cleaning
Consultation/Evaluation
How was your greeting by our receptionist when you arrived?
Excellent
Very Good
Average
Poor
How was the cleanliness/neatness of our waiting room?
Excellent
Very Good
Average
Poor
How was the cleanliness/neatness of our facility?
Excellent
Very Good
Average
Poor
How was the friendliness of our Staff and Doctor
Excellent
Very Good
Average
Poor
Did you have a good understanding of your visit? Did you receive a treatment plan that was explained well?
Yes
No
If you answered No to the above question, please explain.
How was the ease of your check out, paying and making your next appointment?
Excellent
Very Good
Average
Poor
Overall, how would you rate your visit to our office today?
Excellent
Very Good
Average
Poor
If you underwent Surgery today, were the post-operative instructions clear and easy to understand?
Yes
No
If you answered No to the above question, please explain.
If you had a family member or friend in need of Periodontal treatment, would you recommend Pioneer Valley Periodontics to him or her?
Yes
No
If you answered No to the above question, please explain.
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