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First Name

Your Email (for future contact purposes)

I would like to go into the monthly draw to win an Oral B Electric Toothbrush valued at $220.00

Contact Number (for monthly feedback draw prize winners)

Approximately how long after your scheduled appointment time did you have to wait to be seen?I was seen at the scheduled timeI waited 5-10 minutesI waited 10-15 minutesI waited longer than 20 minutes

Were you given an explanation for the delay? Choose "Not applicable" if your scheduled time was met.Yes, and it was satisfactoryYes, and it was unsatisfactoryNoNot Applicable

How satisfied were you with the following? Please tick.

i.The friendliness/courtesy of the reception staff was:Very PoorPoorFairGoodVery Good

ii.The friendliness/courtesy of the dental assistant was:Very PoorPoorFairGoodVery Good

iii.The friendliness/courtesy of the dentist/hygienist was:Very PoorPoorFairGoodVery Good

iv.The punctuality of the dentist/hygienist was:Very PoorPoorFairGoodVery Good

v.The explanations of the dentist/hygienist about my problem/treatment was:Very PoorPoorFairGoodVery Good

vi.The amount of time the dentist/hygienist spends time with me was:Very PoorPoorFairGoodVery Good

vii.The instructions the dentist/hygienist gave me about my follow up care were:Very PoorPoorFairGoodVery Good

viii.The overall cleanliness/tidiness of the surgery was:Very PoorPoorFairGoodVery Good

ix.The cost of treatment in relation to the services provided was:Very PoorPoorFairGoodVery Good

x.Likelihood of me recommending Coburg Dental Group to others wasVery PoorPoorFairGoodVery Good

How long have you been a patient with the practice?Less than a year1 to 2 years2 to 4 yearsMore than 4 years

What did you love most about your visit at the practice?

What improvements would you make to your visit?

Do you have any other comments you wish to make?

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