WELCOME TO PALM VALLEY ORAL SURGERY

We strive to provide the utmost patient care possible and value your opinion about your experience at our facility. Please take a moment to complete the following questions. Your response is confidential.

We are grateful for your time and suggestions.

Name (optional)

Email address (optional)

DOB

Age

Date of your appointment/surgical treatment:

Were you greeted in a friendly manner both initially by phone and at our initial visit to our office?

Yes No

Did the consultation visit answer questions/concerns, and ally anxiety you may have had regarding this visit?

Yes No

Were you kept waiting an unreasonable amount of time to see Dr. Blazic or a member of our staff?

Yes No

Did you find your oral surgery to be a pleasant experience?

Yes No

Better than you originally thought it might be?

Yes No

Were the post-operative instructions adequately explained to you and the person responsible for your post-operative care?

Yes No

Were the financial matters handled in a professional matter?

Yes No

If you had a need for oral surgery in the future, would you return to this office?

Yes No

Suggestions for improvement of our services:

Additional Comments

May we contact you regarding your care at our office?

Yes No

May we contact you regarding this survey?

Yes No

Please provide the best phone number for us to contact you: