Patient Survey

In order to provide better service to fulfill your dental needs, kindly share with us your feelings and experiences concerning your most recent visit by filling out this survey. When you have completed it, please press the Submit button at the bottom of the form.

Thank you in advance for your assistance.
Background Questions

Please indicate all of the services that you have received within the last 12 months.

BracesCleaningCosmeticDenturesEmergency CareExtractionsImplantsPeriodontal CareRestoration

Please indicate your answers to the following based on your last visit with us.

Patient Name:

Visit Date:

Visit Time:

Was this your first time visiting our practice?:

Did the dentist examine you on your visit? :

Are you currently covered by dental insurance? :

What is your main source of payment? :

Opinion Questions
Please indicate your view on your overall experience with our office and staff.

Comfort of the lobby/waiting area :

Cleanliness of facilities :

Front desk staff’s attentiveness to your needs :

Clear explanation of treatment options :

Availability of payment options :

Helpfulness of the staff scheduling your appointment :

Convenience of office hours :

Teamwork exhibited by our dental team :

Thoroughness of exam and treatment :

Professionalism, Attentiveness, and Friendliness of the dental assistant :

Oral hygiene education provided by Doctors/Assistants :

Overall rating of care provided :

Likelihood of recommending our practice to others :

Additional Comments
Please provide any additional feedback regarding our office and staff.


North Brunswick, NJ Office

746 Livingston Avenue
North Brunswick, NJ 08902
Phone: (732) 846-8383
Fax: (732) 846-8395

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Edison, NJ Office

495 Plainfield Avenue
Edison, NJ 08817
Phone: (732) 985-1400
Fax: (732) 985-1955

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Somerset, NJ Office

1323 Rt 27
Somerset, NJ 08873
Phone: (732) 249-0411
Fax: (732) 249-0611

Schedule Online