We hope that you have had a comfortable and pleasant experience in our office. We would greatly appreciate it if you would take a moment to share your impressions of our office. We are always striving to be the best that we can.

1.	Your overall experience in our office	A   B   C
2.	Flexibility in arranging appointments	A   B   C
3.	Handling of your phone calls	A   B   C
4.	Explanation of treatment procedures	A   B   C
5.	Our respect of your time	A   B   C
6.	Courteousness and concern of front office staff	A   B   C
7.	Courteousness and concern of chairside assistants	A   B   C
8.	Courteousness and concern of the doctor	A   B   C
9.	Professionalism and gentleness of chairside assistants	A   B   C
10.	Professionalism and gentleness of the doctor	A   B   C
11.	Comfort of the reception area	A   B   C
12.	Comfort of the treatment area	A   B   C
13.	Our response and attentiveness to your concerns	A   B   C
14.	Our ability to answer your insurance and financial questions clearly and concisely	A   B   C
15.	Would you recommend our office to friends and family?	Yes   No
16.	Please provide any comments that would help us improve our service to you.
17.	Please provide any additional comments.
18.	Please tell us your name.
19.	Please provide your email address.