Patient Survey
Sheri Katz D.D.S. P.C.
What type of appliance do you have?
Your answer
When did you receive your appliance from Dr. Katz?
MM
/
DD
/
YYYY
Please use the following scale: 5=excellent, 4=very good, 3=average, 2=poor, 1=failure. Leave question blank if it is not applicable to you.
Appointments were made in a timely matter
Failure
Excellent
The appliance was custom-made and fit well
Failure
Excellent
Overall satisfaction with the service received from Dr. Katz and her staff
Failure
Excellent
Likeliness to recommend Dr. Katz to others
Never
Extremely Likely
Received adequate information about the treatment process and what to expect.
Failure
Excellent
Written and verbal instructions on how to use the device were clearly communicated
Failure
Excellent
I received information on how to contact the office regarding any questions or concerns I might have about my treatment
Failure
Excellent
Questions, issues and/or concerns were addressed to my satisfaction
Failure
Excellent
Please provide any comments or suggestions:
Your answer
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