Patient Survey Form

Contact our Shelby Township dental office today to learn more about our dentists or to request an appointment.

  • Internal Outcomes Study

    We, the staff of Frank Ruffino DDS, appreciate you allowing us to provide services to you. We are interested in your feedback of the services you received to evaluate our effectiveness and imporve our services to our patients.

    We would very much appreciate your completing this survey. It is not necessary to sign your name. Please feel free to be completely honest.

    Thank you for your assistance.

  • Please rate the following services by selecting the appropriate number:

    • 5 - Excellent
    • 4 - Good
    • 3 - Average
    • 2 - Fair
    • 1 - Unsatisfactory
    • N/A - Not Applicable
  • Signature

    I have read and understand the above Notice of Privacy Practices.

  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.