Riverside Dental Patient Survey Form

Name

(Not Required)

How would you rate your overall visit? *

Very Satisfied
Satisfied
Somewhat Satisfied
Not Satisfied at All

Did the staff treat you professionally on the phone? *

Yes
No

Did the staff greet you properly? *

Yes
No

Were the assistants and hygienist friendly and professional to you? *

Yes
No

Was the doctor professional and courteous to you? *

Yes
No

Did the cleanliness of our practice meet your expectations? *

Yes
No

Were your financial matters handled in a timely and well addressed manner? *

Yes
No

Would you refer us to your friends and family? *

Yes
No

Additional Comments

Security Code: *