Dental Office Visit Patient Feedback

Dental Office Visit Patient Feedback — Form Fields

This feedback template includes 11 fields. Evaluate patient satisfaction with dental care, wait times, and office environment. Free to customize and use on ZenBuild.

• Patient Name (text, optional)
• Email (email, optional)
• Visit Type (dropdown selection, required) — options: Cleaning, Filling, Extraction, Orthodontics, Whitening, Consultation, Emergency
• Your Dentist (dropdown selection, required) — options: Dr. Smith, Dr. Johnson, Dr. Patel, Other
• Approximate Wait Time (multiple choice, required) — options: Under 5 minutes, 5-15 minutes, 15-30 minutes, Over 30 minutes
• Reception Staff Friendliness (rating, required)
• Dentist Explanation of Treatment (rating, required)
• Pain Management (rating, required)
• Office Cleanliness (rating, required)
• Overall Satisfaction (rating, required)
• Any additional comments or concerns? (long text, optional)