Dear Patient,
     The most important thing about being a dentist is ensuring that my patients receive the highest quality of care.
     Your feedback is one of the things that make this possible. Please take a few minutes to submit this quality control survey to markniemiecdds.com.
     Your answers are confidential and you are not required to fill out your name and address.
     I thank you in advance for your help and look forward to servicing your dental needs in the future.
***Dr. Mark Niemiec

All questions are optional. Feel free to answer as many as you feel you comfortably can.

Personal Information

First Name:
Last Name:
Address:

General


1. How long have you been a patient of our practice?

2. When was your last visit?

3. On a scale of 1-10 (10 being the highest), how would you rate the following aspects of our practice:
*A. Staff friendliness & courtesy?

*B. Overall office appearance?

4. What have you liked most about being one of our patients?

5. Have there been any problems you feel we should be aware of? If so, please explain.

Scheduling


6. Have you ever had a problem scheduling an appointment with our office? If so, please explain.

7. When coming on for an appointment what has your average wait time been, if any?

8. What hours are most convenient for you to visit our office?

Patient Education


9. On a scale of 1-10 (10 being the highest), how would you rate the doctor/hygienist ability to explain and answer questions about your dental conditions or concerns?

10. If you gave a low rating, what is the reason?

11. Are you unclear about any aspect of your dental condition or needs?

12. Is there anything we could provide to increase your understanding of your dental condition or needs?

Billing


13. Are you insured? If so, through which company?

14. Have you had any difficulty with your insurance company? If so, please explain.

15. Do you have any unanswered questions about your bill or billing procedures? If so, please explain.

16.Have you had any difficulty with our accounting department?

17. On a scale of 1-10 (10 being the highest), how would you rate our accounting department?

18. If you gave a low rating, what is the reason?

19. Is there anything about our accounting department or our billing that you would like the doctor to know?

Clinical

20. One a scale from 1-10 (10 being the highest), how would you rate the quality of care you have received from our office?

21. If you gave a low rating, what is the reason?

22. What, if anything, do you feel we could do to improve your experience while receiving care?

Other

23. Would you refer friends & family to our office? If no, what is the reason?

24. Anything else you would like the doctor to know?

25. Any other questions or comments?

☺☺

Thank you!