Dental Patient Satisfaction Survey Template

1. What is your age?

The answer should be a single choice:

1. Under 18
2. 18-24
3. 25-34
4. 35-44
5. 45-54
6. 55-64
7. 65 or older

2. What is your gender?

The answer should be a single choice:

1. Male
2. Female

3. How often do you visit the dentist?

The answer should be a single choice:

1. Every 6 months
2. Once a year
3. Every 2-3 years
4. Only when I have a problem

4. How easy was it to book your appointment?

The answer should be a single choice:

1. Very easy
2. Somewhat easy
3. Neutral
4. Somewhat difficult
5. Very difficult

5. Did the receptionist greet you in a friendly manner when you arrived for your appointment?

The answer should be a single choice:

1. Yes, very friendly
2. Yes, somewhat friendly
3. Neutral
4. No, somewhat unfriendly
5. No, very unfriendly

6. Was the clinic clean and well-maintained?

The answer should be a single choice:

1. Yes, very clean and well-maintained
2. Yes, somewhat clean and well-maintained
3. Neutral
4. No, somewhat unclean and poorly maintained
5. No, very unclean and poorly maintained

7. Was the waiting area comfortable and pleasant?

The answer should be a single choice:

1. Yes, very comfortable and pleasant
2. Yes, somewhat comfortable and pleasant
3. Neutral
4. No, somewhat uncomfortable and unpleasant
5. No, very uncomfortable and unpleasant

8. How satisfied were you with the level of care you received from your dentist?

The answer should be a single choice:

1. Very satisfied
2. Somewhat satisfied
3. Neutral
4. Somewhat dissatisfied
5. Very dissatisfied

9. Did the dentist explain the procedures to you in a clear and understandable manner?

The answer should be a single choice:

1. Yes, very clearly and understandably
2. Yes, somewhat clearly and understandably
3. Neutral
4. No, somewhat unclearly and not understandably
5. No, very unclearly and not understandably

10. How satisfied were you with the results of your dental treatment?

The answer should be a single choice:

1. Very satisfied
2. Somewhat satisfied
3. Neutral
4. Somewhat dissatisfied
5. Very dissatisfied

11. Did the dentist or dental hygienist give you tips on how to better care for your teeth and gums?

The answer should be a single choice:

1. Yes, very informative and helpful
2. Yes, somewhat informative and helpful
3. Neutral
4. No, somewhat uninformative and unhelpful
5. No, very uninformative and unhelpful

12. How likely are you to recommend our clinic to family or friends?

The answer should be a single choice:

1. Very likely
2. Somewhat likely
3. Neutral
4. Somewhat unlikely
5. Very unlikely

13. Overall, how satisfied are you with your experience at our clinic?

The answer should be a single choice:

1. Very satisfied
2. Somewhat satisfied
3. Neutral
4. Somewhat dissatisfied
5. Very dissatisfied