PATIENT COMMENT CARD
Thank you for taking a moment provide your feedback!
Which office did you visit?
Date and Time:
Who was your dentist?
How were you treated by the staff and dentist?
Poor
Average
Good
Great
Why did you come into the office?
Exam & Cleaning
Other:
If you received an injection & your mouth was numbed, did the dentist follow up within 24 hrs?
Yes
No
N/A
If you’re a NEW patient, did you receive a welcome note in the mail after your visit?
Yes
No
N/A
How would you rate your overall experience?
Poor
Average
Good
Great
Comments:
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Your Name:
Your Email:
Phone:
