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McQueary Dental

Patient Survey

1. What is your name and email address? (Optional, but required if you would like a chance to win the free Electric Toothbrush)

2. Was this your first appointment with Dr. McQueary? *This question is required.

How did you first hear about McQueary Dental?

3. How would you rate your experience in the waiting room? *This question is required.

4. How would you rate your experience with the hygienist? *This question is required.

5. How would you rate your experience with the Doctor? *This question is required.

6. Did the Doctor treat you with respect and address your dental concerns? *This question is required.

7. How much pain did you experience during your visit? *This question is required.

No pain at all!	Slight discomfort	Painful	Very painful	The worst pain ever!	Not Applicable

8. Would you be interested in minor facial cosmetic procedures offered at this dental office, such as Botox or Restylane? *This question is required.

9. Do you or your partner experience issues with snoring during sleep? *This question is required.

Would you be interested in anti-snoring devices offered at this office?

10. Would you recommend Dr. McQueary to a family member or friend? *This question is required.

If you would like, please give us the name of someone you are going to refer to Dr. McQueary. That way we will know who to thank when that new patient comes in :) You will recieve $25 for each successful new patient referral! You must give your name at the top of this survey to be eligible to receive your reward.

11. Any additional comments about our staff or services?

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