Dental Office Feedback Form

Dental Office Feedback Form — Form Fields

This feedback template includes 8 fields across 2 pages. Collect patient feedback on dental care, staff friendliness, wait times, and office comfort to improve your practice. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Email Address (email, optional)
• Type of Visit (dropdown selection, required) — options: Routine Cleaning, Filling/Restoration, Root Canal, Cosmetic Procedure, Consultation, Emergency Visit
• Rate the friendliness of the front desk staff (rating, required)
• Rate your dentist's communication and care (rating, required)
• How long was your wait time? (multiple choice, required) — options: No wait, Under 10 minutes, 10-20 minutes, Over 20 minutes
• Was pain management adequately addressed? (multiple choice, required) — options: Yes, very comfortable, Mostly comfortable, Some discomfort, Significant discomfort
• Additional Comments (long text, optional)