Patient Survey

Date of Visit

Patient Name (optional)

E-mail address (optional)

1. How would you rate your overall experience at Dr. John Vinings dental practice?
Exceeded my expectations Met my expectations Below my expectations

2. How was the overall professionalism of the staff?
Excellent Good Average Fair Poor

3. Were your needs met by the Doctor?
Yes No
If no, please comment:

4. Were your needs met by your Dental Assistant?
Yes No
If no, please comment:

5. Were your needs met by your Hygienist?
Yes No
If no, please comment:

6. What did you enjoy the most about your experience with us?

7. What can we do to improve our services to you?

8. How would you like to be notified for future appointments with us?
Home* Work* Cell Phone Email
*May we leave a message? Yes No

9. Would you like to be contacted about your answers / comments?
Yes No
Phone Number

Additional Comments: