Patient Survey

First and Last Name (Optional)

Doctor(s) Name (Optional)

Office Location

Choose... Burlington, VT Essex Jct, VT Shelburne, VT South Burlington, VT

Did we attend to you promptly and courteously?
Exceptional	Good	Fair	Poor
Did you find our reception area comfortable?
Exceptional	Good	Fair	Poor
Were you seen on time?
Exceptional	Good	Fair	Poor
If not, did you wait...
< 15 Minutes	15 - 30 minutes	30 - 45 minutes	45 Minutes >
Was our staff courteous and helpful?
Exceptional	Good	Fair	Poor
Would you recommend us to family and friends?
Yes	No
If no, why not?
Were your financial options explained to you clearly?
Exceptional	Good	Fair	Poor
Is there any staff member that you feel should receive special recognition?
How did you hear about us?
Do you have any questions or comments you would like to include?
Would you like us to follow up with you regarding any dental questions or concerns you may have?
Yes	No
If so, please provide us with a phone number where we may contact you.
E-Mail Address