Patent Satisfaction Form (Dental)
We’d love to hear about your customer experience. Feel free to share suggestions, ideas, or anything that comes to mind.
First name
Last name
Phone Number
Email
Please check your annual income.
0-10K
10K-20K
20K-30K
30K-40K
40k-50k
50k-60k
60K- Above
How long have you been a dental patient?
Less than 1 year
1-5 years
5 years
Please rate the friendliness and helpfulness of the office staff who greeted you?
Outstanding
Good
Adequate
Needs Improvement
Poor
N/A
Please rate your satisfaction with your physician/provider?
Outstanding
Good
Adequate
Needs Improvement
Poor
N/A
Do you think the normal charge of $20.00 is affordable under the Sliding Fee Program?
Yes
No
How would you describe the cleanliness of the building?
Outstanding
Good
Adequate
Needs Improvement
Poor
N/A
Would you recommend health center to family or friends?
Yes
No
May we contact you?
yes
no
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