Doctor Feedback Form

The statements below describe how we would like our referring dentists to feel about their referral experience.  Please help us know what we are doing well and where we can improve based on your experience.  In addition to ranking to what degree these statements describe your experience, please share specific comments in the spaces below that will help us know what we can focus on to optimize the experience for you and your patients.

Your office coordinated with me to provide the highest quality care to my patient.

Poor (0)

Average (1)

Good (2)

Excellent (3)

My patient was scheduled in an accommodating manner.

Poor (0)

Average (1)

Good (2)

Excellent (3)

Your service to my patient was delivered in a kind, calming, and caring manner.

Poor (0)

Average (1)

Good (2)

Excellent (3)

You emphasized to my patient the importance of restorative treatment and coordinated their next visit to my office after endodontic treatment was completed.

Poor (0)

Average (1)

Good (2)

Excellent (3)

Case reports describing treatment are informative and provided to me in a timely manner.

Poor (0)

Average (1)

Good (2)

Excellent (3)

My patient was satisfied with his/her treatment experience in your office.

Poor (0)

Average (1)

Good (2)

Excellent (3)

Dr. Widmer and his staff are readily available to me when I have questions before, during, or after treatment.

Poor (0)

Average (1)

Good (2)

Excellent (3)

Any postoperative complications were adequately resolved by your office.

Poor (0)

Average (1)

Good (2)

Excellent (3)

I am pleased with healing success rates that I observe following treatment.

Poor (0)

Average (1)

Good (2)

Excellent (3)

My patient and I feel the treatment provided was valuable and worth the cost.

Poor (0)

Average (1)

Good (2)

Excellent (3)

Your office helps my practice thrive by providing helpful and relevant information to assist me in delivering the highest quality treatment to my patients.

Poor (0)

Average (1)

Good (2)

Excellent (3)

Please offer any additional comments or suggestions to help us improve our service to you.

Dentist Name (optional)

Phone (optional)

Email (optional)

Please contact me regarding these responses

Yes

No

My comments provided on this form may be used in literature by Stanton D. Widmer, DDS.

Yes

No

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