Patient Survey
1=strongly disagree, 2=disagree, 3=neither agree nor disagree, 4=agree, 5=strongly agree
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1.  I was always greeted by a friendly staff. *
2. The staff is professional and knowledgeable. *
3. My initial consultation was professional, informative and organized. *
4. The high-quality treatment I'm receiving is affordable. *
5. At every appointment I receive an update on the progress of treatment. *
6. The orthodontic assistants were attentive and sensitive during my treatment. *
7. Dr. Kuipers was attentive and sensitive during my treatment. *
8. The office uses the most up to date orthodontic procedures and tools. *
9. It is easy to get appointment that work with my schedule. *
10. The office is clean every time I visit. *
11. The office has a friendly and fun environment. *
12. I've visited the Kuipers Orthodontics website. *
13. I am very pleased with my experience at Kuipers Orthodontics. *
14. I enjoyed Kuipers Orthodontics so much I would refer family and friends there for treatment. *
15. What do you like least about your experience at Kuipers Orthodontics? *
16. What do you like most about your experience at Kuipers Orthodontics? *
17. What could we do to make our office and your experience better? *
18. How far do you travel to come to our office? *
Name: *
Email: *
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