Dental Patient Satisfaction Survey

Dental Patient Satisfaction Survey — Form Fields

This surveys template includes 9 fields. Evaluate patient experience with dental care quality, pain management, wait times, and staff communication. Free to customize and use on ZenBuild.

• Visit Type (dropdown selection, required) — options: Cleaning/Check-Up, Filling, Extraction, Root Canal, Whitening, Orthodontics, Emergency
• Patient Type (dropdown selection, required) — options: New Patient, Returning Patient
• Overall Dental Visit Satisfaction (rating, required)
• Dentist Communication and Explanation (rating, required)
• Pain Management (rating, required)
• Wait Time and Scheduling Experience (rating, required)
• Did you feel comfortable during your visit? (multiple choice, required) — options: Very Comfortable, Mostly Comfortable, Somewhat Uncomfortable, Very Uncomfortable
• Services Received (checkboxes, optional) — options: X-Rays, Cleaning, Cavity Filling, Crown, Whitening, Orthodontic Consult, Other
• How can we improve your dental experience? (long text, optional)