Dental Care Survey Template

Dental Care survey including time between visits, evaluation, importance of factors in choosing a dentist, and notification preference.

Do you presently have a dentist that you visit on a regular basis?
How did you find your dentist?
Referral by friend/neighbor
Referral by acquaintance
Referral by another dentist
Referral by doctor
Phone book
Saw office/sign
Do members of your household go to (check all that apply):
One dentist
More than one dentist
An orthodontist
An oral surgeon
Other dental specialist
The most common reason for not going to the dentist is:
I do go for regular check-ups
The cost of care
I don't need to go very often
I forget to go
I don't like dentists
There is nothing wrong with my teeth
How often do you make visits to your current dentist?
< 6 months
6 months - 1 year
1-2 years
2-3 years
3-4 years
4+ years
How often do you go to your dentist for regular checkups?
Every 6 months
At least once a year
At least every 2 years
At least once every 3-4 years
It depends, I go when I have trouble with my teeth
Would you like your dentist to notify you when it is time for a 6-month check-up?
Not sure
If you would like your dentist to notify you when it is time for a check-up, how would you prefer to receive this notice?
Phone call
Text Message
I would prefer the following payment plan for my dental care:
Payment required at the time of care (cash/check)
Payment by charge cards at the time of care (VISA, Mastercard, etc.)
Monthly payment plan at 1.5% interest per month
Payment due within 30 days
Dental charges may vary subject to the amount of time that the dentist takes to complete a procedure, as well as the kind of work performed. If the cost were the same, what kind of dentist would you prefer?
Takes a little longer to get the job done, but talks to you during the procedure (45 minutes time)
Completes the work more rapidly and talks less (30 minutes time)
Completes the work very rapidly (20 minutes time)
Would you expect the dentist who takes longer to do a better job?
Not sure
What do you like best about your personal dentist?
What would you suggest that might make a visit to your dentist more pleasurable?

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