Post-Appointment Survey

1. What service(s) did you have completed during your most recent office visit? Check all that apply. A. Initial Consultation B. Braces Bonded C. Braces Adjustment D. Braces Removal E. Retainer Check

2. Five being the best, how would you rate our facility? 1 2 3 4 5

3. Five being the best, how would you rate our staff? 1 2 3 4 5

4. Would you recommend our practice to family or friends? Yes No

5. Any additional feedback you would like to provide to our office in regard to your recent visit?