PERSONAL DATA

       Age:             

Sex              Male Female

Occupation: 

YOUR APPOINTMENT

Telephone Courtesy:                                    Good Poor

Promptness in getting initial appointment:        Good Poor

Were telephone conversations understandable? Yes No

Are our office hours convenient for you?          Yes No

If no, please explain:

YOUR FIRST VISIT

Was the dental secretary at the front desk friendly, courteous, helpful, efficient, and sensitive?

Yes   Somewhat   No

Was the dental assistant at the chair courteous, helpful, and reassuring?

Yes   Somewhat   No

Were you provided with adequate responses to your questions about treatment?

Yes   Somewhat   No

Was there anything more the dental secretary or chairside assistant could do for you?

Yes   Somewhat   No

If yes, please explain:

OFFICE APPEARANCE

In general, did you find the office clean & sterile, comfortable & appealing?

Yes   Somewhat   No

Did the staff appear clean and sterile?

Yes   Somewhat   No

Do you have individual suggestions for improving the appearance of the:

Reception Room:    

Business Area:      

Treatment Rooms: 

Staff Members:     

DISCOMFORT

Did you experience pain before treatment?

Yes   Somewhat   No

Did you experience pain during treatment?

Yes   Somewhat   No

Did you experience pain after treatment?

Yes   Somewhat   No

EMERGENCY TREATMENT

If you were seen as an emergency patient, were your needs promptly met?

Yes   Somewhat   No

Was proper care and understanding shown?

Yes   Somewhat   No

Can you suggest any ways in which emergencies could be better handled?

Yes   Somewhat   No

If yes, please explain:

DURING YOUR TREATMENT

Was the treatment at our office what you expected?

Yes   Somewhat   No

Was the endodontist sympathetic and sensitive to your feelings?

Yes   Somewhat   No

In your opinion, did the endodontist seem to be an expert?

Yes   Somewhat   No

Was the endodontist gentle, comforting, and did he/she put you at ease?

Yes   Somewhat   No

Was the endodontist informative as to what was going on, and was guidance on what treatment was best for you provided?

Yes   Somewhat   No

Were your medications explained to you, and was it emphasized that you complete antibiotic therapy until all medication is gone? (If applicable).

Yes   Somewhat   No

Did the endodontist and his or her staff work as a team?

Yes   Somewhat   No

In your opinion, was the latest technology used in the procedures?

Yes   Somewhat   No

Did the endodontist seem confident?

Yes   Somewhat   No

FINAL PROCEDURES

Have you been given instructions on how to save knocked out teeth for yourself or those around you that may 'knock out' a tooth?

Yes   Somewhat   No

Were your insurance forms taken care of properly and was your insurance coverage explained to you?

Yes   Somewhat   No

Were your questions regarding dental coverage answered?

Yes   Somewhat   No

Were your questions answered regarding procedure charges?

Yes   Somewhat   No

If you have had Root Canal Treatment or Retreatment, are you aware that you are to return to your dentist for the placement of a permanent restoration?

Yes   Somewhat   No

Did you experience any difficulty with our office procedures for payment of accounts?

Yes   Somewhat   No

If yes, please explain:

ENDODONTIC PROCEDURES

Please rate the following from one to nine as to the degree to which they gave you discomfort, using number one (1) as the most uncomfortable:

1 2 3 4 5 6 7 8 9 Local dental injection     1 2 3 4 5 6 7 8 9 Numb feeling in mouth after injection

1 2 3 4 5 6 7 8 9 Saliva ejector                1 2 3 4 5 6 7 8 9 Rubber dam mouth covering

1 2 3 4 5 6 7 8 9 Bright light                       1 2 3 4 5 6 7 8 9 Drill noise

1 2 3 4 5 6 7 8 9 Clamp on tooth                 1 2 3 4 5 6 7 8 9 Keeping mouth open

1 2 3 4 5 6 7 8 9 Safety glasses

BETWEEN US

On a scale of 1 to 10, with 1=completely dissatisfied and 10=completely satisfied, how satisfied were you with the overall level of service provided by the endodontist and his or her staff? Circle a number from 1 to 10 on the following scale:

1 2 3 4 5 6 7 8 9 10

Please choose one of the two choices that best reflects your feelings in response to the following statements:

I would be pleased to visit this endodontist again for treatment.

Strongly Agree   Strongly Disagree

I would be pleased to recommend this endodontist to my friends and family members.

Strongly Agree   Strongly Disagree

If my regular dentist asked for my opinion, I would advise him or her to send other patients to this endodontist.

Strongly Agree   Strongly Disagree

Was the endodontic treatment successful?

Yes   No   Unsure

How much were you helped by the care you received?

YOUR SUGGESTIONS

Based on your observations and impressions concerning your endodontic treatment, or your child's treatment, please make any suggestions which you feel may be helpful: How could the endodontist and his/her staff make your experience more pleasant?