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Feedback
Printable Feedback Form
[pdf 17 kb]
General Information
How did you find out about the clinic?
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Advertisement
Friend
Referral
Website
Other
How would you rate the access to the clinic
---
Good
Adequate
Needs Improvement
Poor
Scheduling Your Appointment
How did you schedule your appointment?
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Phone
Email
In Person
Website
Was your enquiry handled promptly?
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Yes
No
Was the person who scheduled your appointment courteous and helpful?
---
Outstanding
Good
Adequate
Needs Improvement
Poor
Not At All
Day of Your Appointment
How would you rate the courtesy of the staff at the reception desk?
---
Outstanding
Good
Adequate
Needs Improvement
Poor
Not At All
Which services did you receive during your appointment?
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General Dental
Specialist Services
Prosthetics
How long did you wait in the reception area beyond your scheduled appointment time?
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0-5 Minutes
5-10 Minutes
10-20 Minutes
Other
Your Oral Health Clinician
How would you characterise the demeanor of your clinician?
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Attentive
Concerned
Friendly
Distracted
Rushed
Inconsiderate
Please rate the clarity of the clinician's explanation of your condition and treatment options?
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Outstanding
Good
Adequate
Needs to Improve
Poor
Were your questions answered to your satisfaction?
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Yes
No
The Facility
How would you rate the facility?
---
Outstanding
Good
Adequate
Needs to Improve
Poor
N/A
Would you recommend this facility and its staff to your family and friends?
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Yes
No
How would you rate our concern for your privacy?
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Outstanding
Good
Adequate
Needs to Improve
Poor
N/A
Additional Comments
Please share any additional comments or suggestions
Contact Information
First Name
Last Name
Address
City
State
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ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Email
Telephone
Gender
---
Male
Female
State
Would you like someone to contact you regarding your responses on this survey?
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Yes
No