Patient Forms and Survey

Patient Registration Form

HIPPA Form

Our practice grows from the referrals of our satisfied patients just like you. We appreciate you taking a moment to complete this survey. Please feel free to comment on any part of your visit. Any comments you choose to make will be kept strictly confidential and will assist us in serving you better in the future.

How would you rate your overall visit?

Excellent Very Good Average Not So Good

When your appointment was over, did you have a good understanding of your current dental status?

Yes Not Really I wish I knew more about my situation

Were your financial options explained to you?

Yes No I already understand my financial options

Did you have to wait over 15 minutes past your appointment time to be seated? If so how long?

No 15-30 Minutes 30-45 Minutes Over 45 Minutes

Did our staff greet you when you arrived?

Yes No I don't recall

Did you receive exceptional service from any specific staff member? If so, describe:

Would you refer your friends and family to us?

Yes No I'm not sure

Please comment on your visit - include things that went well as well as areas that could be improved.