Patient Name

(Optional)

   

How would you rate your overall visit?

     Very Satisfied

 

Satisfied

 

  Somewhat Satisfied

 

Not Satisfied
     

Did the staff treat you professionally on the phone?

Yes
No

 

I do not recall

 

   

Did the staff greet you properly?

Yes

 

No

Comments

 

   

Were the assistants and hygienist's friendly and professional to you and your child?

Yes
No
Comments

 

   

Was the doctor professional and courteous to you and your child?

Yes
No

Comments

 

   

Did cleanliness of our practice meet your expectations?

Yes
No

 

   
Were your financial matters handled in a timely and well addressed manner? Yes
No
     
Would you refer your friends and family to us? Yes
No
     
Please comment on how we could make your visit better...

Please type "123" in the box at right to validate your submission.  


 

Cedar Park, TX Pediatric Dentist ~ Dr. Anil Gudapati
Kids Dental Smiles, Cedar Park, Texas

Copyright © 2006 Kids Dental Smiles - Anil Gudapati, D.M.D.  All Rights Reserved.

Click here to read our Disclaimer.   Click here to read our Privacy Policies and Procedures.