Dental Care

There was an error on your page. Please correct any required fields and submit again. Go to the first error.

1. Do you have a regular dentist?

Yes
No

2. How did you come across your dentist?

Family Referral
Friends Referral
Advertisement
Local Phone Book
Other (please specify):

3. Do any family members use the same dentist as you?

Yes, Same Surgeon
Yes, Different Surgeon
No

4. What would you say is the most likely reason for skipping the dentists?

Location
Cost
Fear
Other (please specify):

5. When was the last time you attended the dentists?

Under 6 Months
6 - 12 Months
12 - 24 Months
Over 24 Months

6. How often do you require a check up?

Once Every 6 Months
Once a Year
Once Every 2 Years
Other (please specify):

7. Are you notified when it is time for check up?

Yes
No

8. How are you notified when it is time for a check up?

By Phone
By Email
By Letter
Other (please specify):

9. How do you normally pay for the dentists?

Cash
Debit or Credit Card
Cheque
I Don't Pay
Other (please specify):

10. What do you like the most about visiting the dentists?

11. What suggestions, if any, do you think would improve your dentists?