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Patient Survey

We are constantly striving to provide better treatment and care for our patients. We would like to know how you perceive our services. Please take a few minutes to complete this Patient Survey Questionnaire. Your responses are anonymous and will be used to better the office. Your cooperation is greatly appreciated.

Please use the following scale for your responses: 5. Very Good 4. Good 3. Average 2. Poor 1. Very Poor
1. Please rate the appearance/impression of the following areas:
Waiting Room 54321	Comments...
Reception Desk 54321	Comments...
Treatment Rooms 54321	Comments...
Consultation Room 54321	Comments...
2. Please rate the appearance and professionalisim of our front desk team 54321
3. Please rate your observations as it pertains to our front desk team (specific team members will be helpful)
4. Please rate the appearance and professionalism of Dr. Simon's assistants 54321
5. Please relate your observations as it pertains to Dr. Simon's assistants (specific team members will be helpful)
6. Please relate your observations as it pertains to Dr. Simon 54321	Comments...
7. Please rate the effectiveness of our appointment phone call reminder system 54321	Comments...
8. Did you enjoy your experience at this website?	YESNO
9. Did you know that you could register online to gain access to your personal account information?	YESNO
10. How satisfied are you with the availability of appointment times? 54321	Comments...
11. How do we rate with regards to keeping on time for your scheduled appointments? 54321	Comments...
12. If you needed extra assistance with treatment (emergency appointment), how would you rate the response of Dr. Simon and/or Team? 54321N/A	Comments...
13. How would you rate the way in which the treatment plan was explained to you? 54321	Comments...
14. How satisfied were you with our policy on financial arrangements? 54321	Comments...
15. Based on your experience, how likely are you to recommend our office to family or friends who need orthodontic treatment? Would RecommendUnsureWould Not Recommend
16. Final Comments
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10115 Forest Hill Boulevard, Wellington, FL 33414
3472 Forest Hill Boulevard, West Palm Beach, FL 33406

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