Patient Satisfaction Survey
	Please click to answer "Yes" or "No", fill in answers for the other sections and click the Submit button.  Your name and email address will remain confidential.  Thank-you for participating.
1.	When you phoned to make an appointment, was the staff member courteous?			Yes No
2.	When making an appointment were staff helpful in finding a suitable time?			Yes No
3.	Upon arrival, were you greeted in a friendly manner?			Yes No
4.	Were you made to feel comfortable during your visit?			Yes No
5.	Were you seated in an examination room by your set appointment time?			Yes No
6.	The Dentist/Hygienist took time to listen to your concerns about dental care?			Yes No
7.	The Dentist/Hygienist took time to explain your dental/hygienic treatment plan?			Yes No
8.	Did you feel that you understood the prescribed dental fees?			Yes No
9.	Was the amount on your bill clearly explained?			Yes No
10.	Were payment options regarding your bill discussed?			Yes No
11.	Are you aware of our 0% financing option (OAC)?			Yes No
12.	If you had a concern at your last visit, was it was properly handled by our staff?			Yes No
13.	Did you feel that staff was concerned about your overall well-being as well?			Yes No
14.	Are you comfortable with the level of technology used in our centres?			Yes No
15.	Are you aware that we are currently accepting new patients?			Yes No
16.	Would you like to refer a friend or family member to our office?			Yes No
17.	Would you be interested in a free cosmetic consultation with a Dentist?			Yes No
18.	Would you like to change your smile?			Yes No
19.	Please describe how you would like to change your smile:
20.	Is there anything at Dove that you would like to see improved or changed?
21.	Overall, how would you rate our service?			1 Poor 2 3 4 5 Excellent
22.	May we have consent to publish your name in our offices as the winner, if your survey is selected in our random monthly draw?			Yes No
	Optional First Name
	Optional  Last Name
	Optional Phone Number
	Optional Email Address
	dd-mmm-yyyy  Example:  01-Jun-2009 Survey Date
	or an approximate date Last Appointment Date
	1 London Southdale-Adelaide Ext 1-1 London Southdale-Sleep Centre 2 London Commissioners 3 London Hyde Park 4 Parkhill 5 Kettle-Stony Point 6 Ingersoll 7 Ilderton 8 London Southdale Jalna Dove Centre