ora dental studio
gold coast · river north · south loop · west loop · wicker park

 

patient satisfaction survey

Please fill in all required fields below and click the submit button to send.

* denotes a required field.

TREATING PHYSICIAN:
Who is your ORA doctor:
HOW WERE YOU ORIGINALLY REFERRED TO OUR PRACTICE?
Clinical Reputation of Practice
Eco-friendly Reputation of Practice
HOW SATISFIED ARE YOU WITH THE FOLLOWING?
CONVENIENCE:  
Assistance with billing issues/insurance plans

Excellent
Good
Fair
Poor
N/A
Practice hours

Excellent
Good
Fair
Poor
N/A
Ease and availability of making appointments

Excellent
Good
Fair
Poor
N/A
CARE / TREATMENT:  
Time the Doctor took to explain oral health/condition

Excellent
Good
Fair
Poor
N/A
Thoroughness of consultation

Excellent
Good
Fair
Poor
N/A
Comfort during treatment

Excellent
Good
Fair
Poor
N/A
Cleanliness and presentation of treatment/surgery rooms

Excellent
Good
Fair
Poor
N/A
Aftercare

Excellent
Good
Fair
Poor
N/A
COMMUNICATION:  
Questions answered clearly by Doctor

Excellent
Good
Fair
Poor
N/A
Alternative treatment plans given

Excellent
Good
Fair
Poor
N/A
Questions regarding insurance, forms, and payment plans answered clearly

Excellent
Good
Fair
Poor
N/A
CUSTOMER SERVICE:  
Team was friendly and courteous

Excellent
Good
Fair
Poor
N/A
Waiting times in reception area

Excellent
Good
Fair
Poor
N/A
Emergency call answered promptly

Excellent
Good
Fair
Poor
N/A
Response time to messages left

Excellent
Good
Fair
Poor
N/A
Politeness and professionalism of phone conversations and confirmations

Excellent
Good
Fair
Poor
N/A
Overall how would you rate your experience?

Excellent
Good
Fair
Poor
N/A
COMMENTS:

 
 


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