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Dental Survey Template

A Dental Survey is a specialized questionnaire used by dental practices and clinics to measure patient satisfaction specifically related to their dental care experience.

Key Benefits

The data collected from these surveys is vital for improving patient care and practice management:

  • Measures Clinical Quality and Outcomes
  • Enhances Patient Comfort and Experience
  • Identifies Areas for Staff Training
  • Improves Appointment Scheduling and Communication
  • Increases Patient Retention and Referrals

Get quick patient feedback with our 6-question Dental Survey template. Covering some basic information about the patient and how often they visit, plus important topics like type of treatment, private or government-funded, whether a charge was paid, plus a 5-star satisfaction rating question. There is also an open-ended question for additional comments. Helping to measure clinical quality outcomes, improve patient retention, and increase patient referrals.

Use this template
Number of questions:
6

Questions used in this template

Dental Survey

We appreciate your recent visit to our dental clinic and your trust in our services.

We would like to take this opportunity to ask you a few questions regarding your experience with our clinic. Your feedback is important to us as we are committed to providing the best care possible to our patients.

Your responses will remain confidential and will help us improve our services to better meet your needs. Thank you for your time.

About You

Please provide the following information:

Full Name:
Address:
Postcode / Zipcode:
Date of Birth (DD/MM/YYYY):

Q1. How often do you visit the dentist?

  1. Every 6 months
  2. Once a year
  3. Every 2-3 years
  4. Only when I have a problem
  5. Other (Please specify):

Your Visit

Q2. Was your last dental treatment…

  1. Government Healthcare treatment
  2. Private treatment
  3. Combination of Government Healthcare and Private treatment
  4. Unsure

Q3. What dental treatment did you have?

  1. Examination
  2. X-ray(s)
  3. Scale & polish
  4. Filling(s)
  5. Crown(s)
  6. Extraction(s)
  7. Denture(s)
  8. Bridge(s)
  9. Sedation
  10. Orthodontic
  11. Veneers
  12. Other (Please specify):

Q4. Did you pay a charge for your treatment?

  1. Yes
  2. No

Q4a. If yes, how did you pay?
(Please specify below)

Q5. On a scale of 1 to 5, how satisfied are you with the dentistry you received?
(1 = Very dissatisfied, 5 = Very satisfied)

  1. 1
  2. 2
  3. 3
  4. 4
  5. 5

Q6. Please use the space below to give any further feedback:

Thank you for your time.

Thank you for taking the time to complete our patient satisfaction survey. Your feedback is extremely valuable to us and will help us improve our services and ensure that we are meeting the needs of our patients.

At our dental clinic, we are committed to providing high-quality care and exceptional customer service. We appreciate your trust in us and look forward to serving you in the future.

If you have any additional comments or feedback, please feel free to contact us at any time.