Please fill out the form below and click the SUBMIT button to send us your comments. Because your comments are sent over the Internet, please do not include sensitive or personal information on this form.

Name (optional):

1. Are you pleased with the manner in which you and/or your child has been treated in our office?

yes no

Comments:

2. Are you happy with your results?

yes no

Comments:

3. How did you choose our office?

4. Did you visit another orthodontic office before choosing our office?

yes no

Comments:

5. Were the financial arrangements clearly explained and convenient?

yes no

If not,why?

6. Were there employee(s) who gave you especially good care and service?

yes no

Comments:

7. Were there any employee( s) you had difficulty with?

Explain:

8. Did you feel free to ask questions during your visits?

yes no

Were they explained thoroughly?

yes no

Comments:

9. How would you rate your overall experience with our office?

Poor Fair

Comments:

10. Would you consider us again or refer a friend or relative to us?

yes no

Comments:

Please list any additional suggestions on the back of this form which you would like to share with us in order to improve our services. Your comments may be helpful in making any needed changes or improvements. Please also indicate if you would like a personal response to your comments. Thank you.

Thank you for sharing your comments with us!