Patient Survey | Shelby Township MI Dentists

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.

Name of Your Provider*

What type of service did you receive?*

Initial Assessment
X-Rays
Follow up/Ongoing Service
Hygienist Only
Annual/Semi-Annual Exam
Other

If other, please specify

Please rate the following services by selecting the appropriate number:

5 - Excellent
4 - Good
3 - Average

2 - Fair
1 - Unsatisfactory
N/A - Not Applicable

Prompt & helpful scheduling of your initial appointment:*

Location of our office:*

Parking:*

Comfort of reception waiting area:*

Courtesy of office staff on the phone:*

Courtesy of office staff in the office:*

Clear understanding of fees prior to treatment:*

Promptness of provider of service:*

Cleanliness & pleasantness of the provider office:*

Your provider's understanding of your condition:*

Your provider's listening skills:*

Clear understanding of goals & treatment plan by you and your provider:*

Helpfulness of your treatment:*

Assistance with filing insurance claims:*

Helpfulness of staff with billing questions:*

Quality of assistance from answering service/machine:*

Rate your general state of dental health prior to treatment:*

Rate your general state of dental health after your treatment today:*

Rate your general state of dental health after your treatment was completed:*

Rate your ability to sustain any positive strides you made in treatment with this provider:*

Rate your likelihood of continuing or returning to treatment with this provider:*

Rate your likelihood of recommending this provider to a friend:*

Comments & Suggestions

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

Patient Printed Name*

Date*

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Phone

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Patient Survey Form

Internal Outcomes Study

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