Patent’s Questionnaire

Dear patient,
in our clinic we are constantly monitoring the quality of our services. You are welcome to evaluate the quality of our services via this anonymous form. Please carefully read the following questions and choose the answer which correspond to your opinion. If your answer is between two opposite answers, please, choose a mark from 1 to 5 which corresponds better to your opinion (marks as in school).

We will be glad to receive your sincere answers.

Thank you for your time and comments.

Fill in form

Your sex


Your age


You use our service


What was the reason of your visit of our clinic?


The treatment was performed by


Were you satisfied with the work of our reception desk?


Were you invited to the dental office in time (as set in your appointment)?


Did the dentist manage to explain you all necessary information regarding your treatment?


Were you satisfied with the approach of the dentist/dental hygienist?


Were you satisfied with the approach of dental assistant?


Were your overall satisfied with your visit to our clinic?


Were you informed in advance about the price of your treatment?


Do you consider the price to be appropriate?


Do you plan to visit our clinic again?


Would you recommend our clinic to other people?


Do you want to share with us any additional information (what you liked or did not like, tips for improving our services)?


Do you prefer to be contacted by the clinic management (to solve the problems or complaints)?

(please state your name and email or mobile number)