Home
About Us
Services
Contact Us

Patient Experience Survery

Please complete the form below; for best results use Google Chrome or Mozilla Firefox browsers.

Patient Experience Survey

We understand and appreciate that you have chosen to transfer to a different dental office. We hope that you would be able to spare a moment to share your thoughts about your experience with us as we would greatly appreciate your feedback. Your responses will help us improve the care that we provide to all of our patients in the future. Please answer the following questions honestly. Your responses will remain confidential.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE TREATMENT AND CONSENT TO THE USE OF SDF:

Reason for Transfer Please select the primary reason(s) you decided to transfer to a different dental office:

Relocation / Moving to a new area
Insurance changes
Dissatisfaction with care (please specify below)
Scheduling / office hours issues
Financial reasons
Other (Please List Below)

Other reasons:

Overall Satisfaction How satisfied were you with the care you received at our dental office?

Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied

Quality of Service: Please rate our Wait times for appointments:

Excellent
Good
Fair
Poor

Quality of Service: Please rate our Care provided by your dentist:

Excellent
Good
Fair
Poor

Quality of Service: Please rate our Cleanliness of the office:

Excellent
Good
Fair
Poor

Quality of Service: Please rate our communication and friendliness of the front office staff:

Excellent
Good
Fair
Poor

Quality of Service: Care provided by the dental hygienists and assistants:

Excellent
Good
Fair
Poor

Quality of Service: Staff professionalism:

Excellent
Good
Fair
Poor

What could we have done better? Please provide any suggestions or feedback on how we can improve our services or your experience with us:

Would you consider returning to our dental office in the future?

Yes
No
Maybe (please detail below).

Maybe details: (Return to office)

Would you recommend our dental office to others?

Yes
No
Maybe (please detail below).

Maybe details: (Recommend out clinic to others)

Additional Comments Please feel free to share any additional thoughts or comments about your experience with us:

We appreciate you taking the time to share your feedback. If you have any questions or would like to discuss your responses further, please don't hesitate to reach out to us. Sincerely, Dr. Dana Price, DMD Lisa Daruwala, manager And the Blue Heron Dental Group

Name

New To The Clinic ?

Blue Heron Dental Group is built on a strong reputation of over 30 years of service to the Ottawa community and the families who live here. Other dentists in the community refer pediatric patients to our clinic due to our experience and reputation when treating children.

Have A Question? Call Us