Dental Treatment Feedback Form

Thank you for choosing our practice for your dental care. We value your feedback to help us improve our services. Please take a few minutes to complete this form.

Patient Information (optional)

Name:
Date of Visit:	____ / ____ / ______

1. Booking & Reception

• How easy was it to book your appointment?
  ☐ Excellent ☐ Good   ☐ Fair   ☐ Poor
• How would you rate the friendliness and professionalism of our reception staff?
  ☐ Excellent ☐ Good   ☐ Fair   ☐ Poor

2. Treatment Experience

• How would you rate the explanation of your treatment plan and options?
  ☐ Excellent ☐ Good   ☐ Fair   ☐ Poor
• Were you made to feel comfortable during your treatment?
  ☐ Yes, completely ☐ Somewhat   ☐ Not really
• How would you rate the overall quality of the dental treatment you received?
  ☐ Excellent ☐ Good   ☐ Fair   ☐ Poor

3. Facilities

• How would you rate the cleanliness and comfort of the clinic?
  ☐ Excellent ☐ Good   ☐ Fair   ☐ Poor

4. Overall Satisfaction

• Overall, how satisfied are you with your visit?
  ☐ Very Satisfied ☐ Satisfied   ☐ Neutral   ☐ Dissatisfied

5. Additional Comments

________________________________________________________________________________________________
________________________________________________________________________________________________
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Consent (optional)

☐ I am happy for my feedback to be used (anonymously) for staff training.
Signature: ___________________________   Date: ____ / ____ / ______