Patient Satisfaction Survey
ASO routinely monitors patient satisfaction as part of its continuing evaluation of each dentist's professional services, and also to assure that Fund members are treated in a friendly congenial office atmosphere. Patient impressions are invaluable in this effort, and we ask your help by completing this survey.

Dentist Name:

Location:

Please rate the care that you received: Excellent Good Fair Poor

Please rate the general office environment: Excellent Good Fair Poor

Were you offered convenient appointments? Always Often Rarely Never

Were appointments kept promptly? Always Often Rarely Never

Were you given a thorough explanation of your treatment options? Yes No

Was the office staff courteous and competent? Yes No

How many years have you been a patient of this office?

Would you recommend this dentist to others? Yes No

Did you incur any charges? Yes No

If you did, how much and for what?

Your comments and suggestions, please.

Your Name (Optional):

Telephone Number: