Name (Optional)

Referred By

Service Provided

Were you treated with dignity and respect by our front desk receptionists?  Yes   No 

Handshakes  Yes   No 

Smile  Yes   No 

Standing up to greet you  Yes   No 

Given a feeling of being cared for  Yes   No 

Were you treated with dignity and respect by our dental assistants?  Yes   No 

Called by name  Yes   No 

Handshake  Yes   No 

Appropriate explanations provided  Yes   No 

Given a feeling of being cared for  Yes   No 

Were you treated with dignity and respect by our dentists?  Yes   No 

Cared for in a professional, nurturing manner  Yes   No 

Family member or designated adult actively involved in post-procedure education  Yes   No 

Advised dentist would phone in the evening  Yes   No 

Emergency phone number given  Yes   No 

Handshake when leaving  Yes   No