Tell us about your experience in our office...

Please rate on scale - 1 being poor and 5 being excellent.

Was the reception area, treatment room(s), and restroom orderly and tidy?
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Were you seen in a timely fashion?
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Were you greeted promptly and courteously?
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Were all your questions and concerns addressed?
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In general, how was your appointment with the hygienist?
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Do you feel like your teeth were cleaned properly?
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If you had particular concerns or conditions, were these addressed?
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Was your experience with the hygienist painless?
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In general, how was your visit with Dr. Applegate and his assistants?
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Was your restorative experience painless?
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Feel free to tell us a more including (optionally) your name.

Name

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Additional Comments

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Do you have a friend or family member who might benefit from our service? If so, provide their name and mailing address below and we will send them information about our office.

Friend Name

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Friend Address

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Security
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