Patient Survey

In order for KK Dental to better service your dental needs, please 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.

Braces
Cleaning
Cosmetic

Dentures
Emergency Care
Extractions

Implants
Periodontal Care
Restoration

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?	Yes No
Did the dentist examine you on your visit?	Yes No
Are you currently covered by dental insurance?	Yes No
What is your main source of payment?	Self-Pay Preferred Provider Private Insurance

Opinion Questions

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

	Very Poor	Poor	Fair	Good	Very Good
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.

Thank you for taking the time to fill out this survey.