How did you first hear about us?

What made you choose us as your dental office?
(Choose all that apply)

Ad (newspaper or magazine)Website (internet)Yellow PagesThrough my insuranceBrochure received in the mailOther (please specify)

Quality of workLocationPriceFriendly staffGreat serviceUp to date technology in the officeOther (please specify)

How long have you been a regular patient with us?

How often do you make dental visits?

This is my first visitLess than 1 year1-2 years3-4 years5-9 years10+ years

QuarterlyEvery 6 monthsYearlyOnly when I have painOther (please specify)

What days of the week would you prefer to have your dental appointments?

What appointment times are preferred?

MondayTuesdayWednesdayThursdayFridaySaturday

7 a.m9-11 a.m12-2 p.m3-5 p.mAfter 5 p.m

How do you prefer requesting an appointment?

For appointment confirmation reminders, do you prefer?

Through our websiteVia E-MailMobile phoneHome numberWork number

Text messageE-MailVoice message on mobile phoneVoice message on home phoneVoice message on work phone

What type of music would you like to hear in our office?

What would you prefer to watch during a dental appointment?

PopularClassicalJazzBig Band60s70s80sOther

Live television/cableAction moviesRomance moviesComedyOtherNone, I will try to take a nap

Into what age group do you fall?

What refreshments would you prefer to have in the reception/waiting area?

20 years and under21 years to 40 years41 years to 60 years61 years and over

Bottled waterCoffeeTeaJuice

Which of the following professional teeth whitening services interest you?

Would you recommend us to your friends and family to take care of their dental needs?

1 hour, in-office whitening (Zoom)Custom traysPre-loaded disposable whitening traysI am not interested in teeth whitening

YesMaybeNo (please explain)

What is the best way to let you know about new services or special on current ones?
(Choose all that apply)

Which of the following would you like to see in the reception/waiting area?

E-MailFacebookNewspaper AdMailSign on buildingDentist newsletterOther (please specify)

TelevisionFishMagazine (please specify what type)Crossword puzzlesPeace and quietOther

To make your appointment more comfortable, which would you want available?
(Choose all that apply)

In which areas does our staff make you feel comfortable? (Choose all that apply)

Nitrous oxide (laughing gas)Conscious sedationBlanketsNeck pillowMusicMovieOther

Sincere concernHygiene treatmentFinancial arrangementsCommunicationConvenienceValueServiceQualityManagement of discomfortWaiting timeMake you feel specialDoctor treatmentOther (please specify)