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Patient’s Name: DOB:


Date of Service:Your Dentist:

 

1. How was the procedure?


2. Was it what you expected?- If No, Please explain.

3. Were you happy with the care provided?if No, Please explain.

4. Were the instructions given appropriate/helpful?- If No, Please explain.

5. Were there any problems with nausea or vomiting?- If Yes, Please explain.

6. Were there any problems with appetite?- If Yes, Please explain.

7. Were there any issues with temperature?- If Yes, Please explain.

8. How are you doing since the procedure?

9. Any other comments for us?

10. What can we do better?