2. 

3. How long did you have to wait before you were seen at each of the following visits?
a. consultation ___________
b. surgery ___________
c. postoperative appointment ___________

4. Was the office clean, neat and professional? yes no

5. Did you like the decor of sports memorabilia? yes no

6. Was the staff friendly, informative and reassuring to you? yes no

7. Have you or your family ever been to our office before? yes no

8. Would you return again if you or your family needed treatment? yes no

9. Would you recommend us to your family and friends? yes no

10. If you would not return or not recommend us to others, why?
___________________________________________________________
___________________________________________________________
___________________________________________________________

11. If any staff members were especially helpful or kind to you, please let us know.
___________________________________________________________
___________________________________________________________

12.Please rate our practice according to the following categories:
a. atmosphere excellent very good good fair poor
b. decor excellent very good good fair poor
c. staff excellent very good good fair poor
d. music excellent very good good fair poor
e. consultation excellent very good good fair poor
f. handouts excellent very good good fair poor
g. surgery excellent very good good fair poor
h. anesthetic excellent very good good fair poor
i. fees excellent very good good fair poor
j. postoper care excellent very good good fair poor
k. overall opinion excellent very good good fair poor

13. Do you have any suggestions or comments, good or bad, that would allow us to learn more about the quality of care we provide for our patients and to help us in the future with other patients. You may use the back of this page if you wish. _______________________________________________________________

_______________________________________________________________

_______________________________________________________________

Thank you for taking the time to share your thoughts with us.
It can only help us to improve our service to you!

Please send completed questionnaire to:

Doctor Gerald M. Silverman
600 Tecumseh Road East, Suite 148
Windsor, Ontario
Canada N8X 4X9
1-519-258-6766
1-519-258-7899

drsilverman@dentalimplants.net