Patient Survey

A. Communicate with us about the Web Site

       We believe that one of the big reasons that people  don't get the results they want from dentists is that

1. Most people don't have the information they need to make good decisions and choices.
2. Many people are fearful of the dental treatment so they put it off and things just get worse.
3. People feel that the work is too expensive for them.

The purpose of this web site is to become a resource for the patient to get access to the information that you believe is useful to help you plan your own happy dental future.

Please take the opportunity to communicate with us and let us know how we can make this web site better and more valuable to you.

1.  Tell us what subjects we should add to the web page.

2.  Tell us what we should so to make it easier to find our web page.

3.  Tell us what we should do to make it easier to navigate around on our web site once you get here.

4.  Anything else?

If you want a reply:

Name:

Email address:

B.  Communicate with us about your experience as a patient at Comfortable Care Dentistry. In order to keep improving, we need feedback. In the office we regularly survey our patients by now, you can communicate with us 7 days a week, 24 hours a day. Please only fill this out if you have been a patient in the practice.

1.  My last dental appointment was (approximately):

2. I consider myself to be a: 

 please select one
A. New Patient: only 1-3 office visits
B: Regular patient: come regularly for cleanings and check ups
C: Long term patient;but don't get regular cleanings and check ups

3.  My family members come to Comfortable Care Dentistry:  

please select one
YES NO

4.  My primary reason for coming to the dentist was (check only one please):  

A. Cosmetic dental care to improve my smile
B: General check up
C: Fix cavities
D: Head, neck or facial pain that could be due to bite problems (TMJ)
E: Broken tooth or toochache needing emergency care
F: Gum problems
G: Other
if Other

5.  As a dental patient I:  

A. Go regularly for exams and checkups (twice a year most of the time).
B. Go only every 1 to 2 years for cleanings and check ups.
C. Go only when I have a specific problems such as broken tooth, discomfort, etc.

6.  If you don't go regularly for dental exams and cleaning, please tell us why:

A. Fear of discomfort at the dentist
B. If no problem, no reason to go.
C. Time is a problem for dental appointments.
D. Expense of dental procedure keeps me away.

7.  The main reason I selected Comfortable Care Dentistry was:

A. Referral by a friend or family member
B. Convience of location. Close to work or home.
C. Availability of convenient hours for appointments (choose below which):

8.  Initially, I heard about Comfortable Care Dentistry by:

A. Friend or family member
B. Article in newspaper or radio or tv interview
C. Mailing D. Yellow pages

9.  In general, regarding my care at the office, I was (select one please):

A. Extremely pleased and would certainly share my experiences with others.
B. Generally happy
C. Treatment was average
D. I was less than happy with my care (see #13 below)

10.  The specific doctor, treatment coordinators, financial/scheduling coordinators or hygienists that made me feel cared for at Comfortable Care Dentistry were:

Names: 

Don't remember: 

select here YES NO

11.  Please fill in this short survey to rate your experience at Comfortable Care Dentistry. When you enter your scores, (5 is high, 1 is low).

select here 5 4 3 2 1

a.  The level of office cleanliness select here

select here 5 4 3 2 1

b.  The way that the doctor explained select here

select here 5 4 3 2 1

c.  The comfort of reception room select here

select here 5 4 3 2 1

d.  The level of treatment comfort select here

select here 5 4 3 2 1

e.  The way the staff showed their care select here

select here 5 4 3 2 1

f.  The handling of financial arrangements select here

select here 5 4 3 2 1

g.  The promptness of the staff's attention select here

select here 5 4 3 2 1

h.  The way the doctor seemed to care select here

select here 5 4 3 2 1

i.  The level of office parking convenience select here

select here 5 4 3 2 1

j.  The general office atmosphere select here

select here 5 4 3 2 1

k.  The telephone reception select here

select here 5 4 3 2 1

l.  The way the staff & doctors seemed to care select here

select here 5 4 3 2 1

m.  The convenience of the office hours select here

select here 5 4 3 2 1

n.  The likelihood I'll tell friends about the office select here

12.  Was there a staff member who was especially helpful?

13.  What I like about Comfortable Care Dentistry is:

14.  What I don't like about Comfortable Care Dentistry is:

15.  My specific suggestion for improving Comfortable Care Dentistry from the patients perspective are:

Thank you for taking the time to help us help you better, Dr. Walter Kostrzewski & the entire staff of Comfortable Care Dentistry

If you want a response:

Name:

Email address:

Date: