Patient Feedback Form

The statements below describe how we would like our patients to feel about their 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 space provided that will help us focus on ways to optimize the experience for you and other patients.

Poor (0), Average (1), Good (2), Excellent (3)

I was treated with friendliness and respect by skillful people who were happy and attentive to my needs.

Poor (0)

Average (1)

Good (2)

Excellent (3)

Scheduling, insurance, and financial transactions were completed in a convenient and accommodating manner.

Poor (0)

Average (1)

Good (2)

Excellent (3)

The problem, proposed treatment, and alternatives were explained in a way that I could understand.

Poor (0)

Average (1)

Good (2)

Excellent (3)

My questions and concerns were addressed to my satisfaction.

Poor (0)

Average (1)

Good (2)

Excellent (3)

State-of-the-art technology and techniques were used to provide me with the best possible treatment.

Poor (0)

Average (1)

Good (2)

Excellent (3)

The anesthetic was given as gently as possible.

Poor (0)

Average (1)

Good (2)

Excellent (3)

The treatment experience was comfortable with minimal or no pain.

Poor (0)

Average (1)

Good (2)

Excellent (3)

I value the treatment I received and feel it was worth the investment for my health.

Poor (0)

Average (1)

Good (2)

Excellent (3)

The dental office was clean and comfortable.

Poor (0)

Average (1)

Good (2)

Excellent (3)

The doctor and staff effectively conveyed genuine concern for me.

Poor (0)

Average (1)

Good (2)

Excellent (3)

After-treatment instructions, medications, and availability of the doctor helped my recovery to be as pleasant as possible.

Poor (0)

Average (1)

Good (2)

Excellent (3)

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

Name (optional)

Phone (optional)

Email (optional)

Please contact me regarding these responses.

Yes

No

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

Yes

No

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