Feedback and Complaints Form

Patient's Name*

Patient's Email*

Your visit was on: (YYYY-MM-DD)

Contact Phone Number*

Overall rating for this dentist:

Not applicableYes, I would recommend this practice to a friendNo, I would not recommend this practice to a friendI prefer not to express my opinion on this

How satisfied were you with the time you had to wait for an appointment?

Not applicableVery satisfiedSomewhat satisfiedNeither satisfied nor dissatisfiedSomewhat dissatisfiedVery dissatisfied

Were you treated with dignity and respect by staff at the practice?

Not applicableAt all timesMostlySometimesRarelyNot at all

How satisfied were you that the dental practice involved you in decisions about your care?
Not applicableVery satisfiedSomewhat satisfiedNeither satisfied nor dissatisfiedSomewhat dissatisfiedVery dissatisfied

How satisfied were you with the information given by the practice on the cost of your treatment?

Not applicableVery satisfiedSomewhat satisfiedNeither satisfied nor dissatisfiedSomewhat dissatisfiedVery dissatisfied

How satisfied were you with the outcome of your treatment?

Not applicableVery satisfiedSomewhat satisfiedNeither satisfied nor dissatisfiedSomewhat dissatisfiedVery dissatisfied

Can you tell us briefly what you liked or disliked about your visit?

What could have been improved upon?

Please summarise your overall experience in a single sentence.

We would love to hear your feedback, thank you!

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