Dr. Jamila M. Narkiewicz

139 South Main Street Milpitas, California 95035

408-942-1010

Patient Survey

Thank you, for choosing our dental practice to help you maintain good oral health. We appreciate your trust and confidence in us. We are here to render caring, quality dental care, promptly and professionally, in a pleasant and friendly atmosphere. We put our patients first in all we do. We appreciate you taking the time to complete our survey. We aspire to consistently maintain high standards of excellence and patient satisfaction. Your input will help us improve and serve you better. Any comments you make are kept strictly confidential and can only help us become better.

Doctor's Name

Patient Name

E-Mail address

Phone

How would you rate your overall visit?

Excellent Adequate Poor

Were you greeted when you arrived?

Yes Not Really I don’t recall

Was the Receptionist helpful?

Yes Not Really Not at all

Were you seen by the dentist in a reasonable amount of time?

Yes No

If you answered no to the above question then how long was the wait?

15-30 minutes 30-45 minutes Over 45 minutes

Were your financial options explained to you?

Yes No No I already understand my financial options

Did you understand the cost before the treatment was started?

Yes Not really No

How was the quality of Care?

Excellent Adequate Poor

Did your dentist manage your Discomfort?

Yes Not Really I am still in a lot of pain

How was your cleaning?

Excellent Adequate Poor

Was the Assistant helpful and courteous?

Yes Not Really No

How would you rate the Cleanliness of our office?

Excellent Adequate Poor

When your appointment was over, did you have a good understanding of your dental situation?

Yes Not really I wish I knew more about my situation

Would you recommend your friends and family to us?

Yes No I am not sure

Please comment on how we can make your visit better.