Survey

This survey is for internal use only and will not be published. Your information will remain confidential to us.

Name *

First

Last

Email *

Location Visited *

Last Visited? *

1. How easy was it to schedule an appointment? *

2. Please rate the initial reception you received upon your arrival. *

3. Please rate the level of comfort and cleanliness of the facility. *

4. Was your waiting time reasonable? *

5. Were you given clear explanations of your treatment and procedure? *

6. Were you given clear answers to your questions and concerns? *

7. Were you given clear instructions for your post appointment care? *

8. Please rate your overall experience with us. *

Phone

Book an Appointment

Preferred Date and Time

Date

Time

First Name *

Last Name *

Street Address Line 1 *

Street Address Line 2

City *

Province *

Postal Code *

Email *

Home Phone *

Mobile Phone *

Are you new to Portrait Dental? *

If yes, how did you hear about us? *

Type of Treatment *

Is there anything in particular that you are concerned about that you want the dentist/hygienist to address? If so, please specify.

Message