Give Us Your Feedback

Patient’s Name:      DOB:

Date of Service:      Your Dentist:


1. How was the procedure?

2. Was it what you expected? - If No, Please explain.

3. Were you happy with the care provided? if No, Please explain.

4. Were the instructions given appropriate/helpful? - If No, Please explain.

5. Were there any problems with nausea or vomiting? - If Yes, Please explain.

6. Were there any problems with appetite? - If Yes, Please explain.

7. Were there any issues with temperature? - If Yes, Please explain.

8. How are you doing since the procedure?

9. Any other comments for us?

10. What can we do better?

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