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• Sample Copy to Accompany the Patient Satisfaction Survey

• Sample Patient Satisfaction Survey

SAMPLE COPY TO ACCOMPANY THE PATIENT SATISFACTION SURVEY

Dear [Insert Patient’s Name]:

We want your feedback. We’re interested in learning about your recent visit to [insert practice name].

The information you provide will be anonymous and combined with answers we receive from other patients.

Please let us know what we’re doing right, and how we can improve the patient experience, by completing this survey by [insert due date for responses].

Thank you for your valuable input.

Sincerely,

Dentist Name

Title

If the email includes commercial content, such as advertising or a message promoting a product or service, comply with the CAN-SPAM Act (for example, CAN-SPAM requires that the email include your physical postal address and instructions for opting out of future emails from you). You must promptly honor any opt out requests.

SAMPLE PATIENT SATISFACTION SURVEY

Please let us know how we’re doing. For each of the following topics, please rate [insert practice name] on a scale of 1 to 4, with 1 indicating the lowest level of satisfaction and 4 indicating highly satisfied.

	notsatisfied			highlysatisfied
1. I had an overall positive experience during my last appointment.	1	2	3	4
2. I was greeted in a prompt and friendly manner.	1	2	3	4
3. The treatment I received was clearly explained.	1	2	3	4
4. The person who provided my dental care was sensitive to my concerns.	1	2	3	4
5. It was easy to schedule my next appointment.	1	2	3	4
6. I would return to [insert practice name] in the future.	1	2	3	4
7. I would be comfortable recommending [insert practice name] to others.	1	2	3	4
8. The one thing I like most about [insert practice name] is:
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