Dental Office Patient Feedback Survey

Dental Office Patient Feedback Survey — Form Fields

This surveys template includes 10 fields. Gather patient opinions on dental care quality, comfort, and office environment. Free to customize and use on ZenBuild.

• Patient Name (text, optional)
• Type of appointment (dropdown selection, required) — options: Routine Cleaning, X-Rays, Filling, Extraction, Orthodontics, Cosmetic Procedure
• Comfort During Treatment (rating, required)
• Dentist Explanation of Procedures (rating, required)
• Friendliness of Front Desk Staff (rating, required)
• Cleanliness of Office (rating, required)
• Were you seen on time? (multiple choice, required) — options: Yes, right on time, Within 10 minutes, 10-30 minutes late, More than 30 minutes late
• Any concerns or suggestions? (long text, optional)
• Would you recommend this office to others? (multiple choice, required) — options: Definitely, Probably, Unlikely
• Email for appointment reminders (email, optional)