VINA Patient Survey
Please take this short (5 minutes or less) survey to help us understand your experience at VINA and how we can improve! We ask about your "story" at VINA to help us market our programs to funders and donors. Please email sjorgens@vinadental.org  if you have any questions or if you would like to talk in-person or over the phone about your experience at VINA. Thank you!
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How would you rate your experience at VINA? *
What is your age?
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How did you hear about VINA?
What type of appointment did you have? (check all that apply)
Is there anything that would have kept you from making or keeping your appointment? (such as: transportation, schedule, finances, payment options, employment, COVID, etc.)
Is there anything we can do to make your experience at VINA better?
Are you in need of any of the following services? (if you check yes, please leave your contact information at the end of this survey so we can connect you with other organizations that offer these services)
Please share your story of your dental needs and experience at VINA (if you are comfortable doing so). How would you describe your experience at VINA? How does VINA impact your life, if at all? (These answers help us continue to fund VINA with donations, grants, etc.)
Please enter your contact information (Name, phone, email)
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