EmailMe Form - Feedback

Name *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Mobile

Alternate phone

Date Time

MM / DD / YYYY

How did you report to this clinic for treatment, the first time ? (kindly select appropriately)

Did you understand clearly about the dental and related problems you have/had and about the treatment procedures performed on you ?

Yes

No

Did you experience problems while undergoing treatment?

Yes

No

Evaluate the following statements.

	Poor	Satisfactory	Good	Excellent
Service	1	2	3	4
Reception	1	2	3	4
Behaviour and attitude of staff	1	2	3	4
Behaviour and attitude of dentists	1	2	3	4
Promptness in service	1	2	3	4
Facilities	1	2	3	4
Treatment provided	1	2	3	4
General clinic arrangements and set up	1	2	3	4
Cleanliness of clinic and surroundings	1	2	3	4

Are you aware of the various treatment facilities offered by the clinic

Yes

No

What do you feel about the professional fees being collected towards treatment and allied services in our clinic ?

Low

Moderate

Excessive

Your suggestions for our clinic

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overall rating