Consultation Date

MM

DD

YYYY

Please click on the option that most reflects your satisfaction with staff interaction during your consultation.

How did you hear about our practice?

Word of Mouth

Physician referral

Internet

Other

Did your consultation meet/exceed expectations?

Yes

No

When your consultation was over, did you have a good understanding of your treatment plan?

Yes

No

I wish I knew more

Time spent in waiting room

Completely Satisfied

Satisified

Somewhat Satisfied

Dissatisfied

Completely Dissatisfied

Time spent with provider

Completely Satisfied

Satisfied

Somewhat Satisfied

Dissatisfied

Completely Dissatisfied

Do you have any suggestions to improve the consultation experience?

Yes

No

If you decided not to schedule a treatment at this time, please indicate the most important factors in that decision:

The financing options discussed with me were inadequate

The cost was too great

The provider and I were not on the same page

Other

Would you refer friends and family to us?

Yes

No

I'm not sure

How would you rate your overall experience at our practice?

Excellent

Very Good

Average

Not So Good

Disappointing

Name

First Name

Last Name