Dental Visit Feedback Survey
Comfort, pain management, cost clarity, and hygiene – the things dental patients remember.
4 questions · 1 page · about 2 minutes to answer · fully editable after you start
Dental anxiety is real, and it is shaped by exactly the things this survey asks about: whether pain was managed, whether each step was explained before it happened, and whether the bill matched what was quoted. Cost surprise, not the drill, is the most common reason patients do not come back.
Send after every completed treatment. Trend the pain-management and cost-clarity scores by practitioner and procedure type to find where the practice loses returning patients.
Template preview
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Opens in the Light theme, or in your own default theme if you have set one — change it anytime to any of the 4 built-in looks, or build your own on a paid plan.
Page 1
Your dental visit
Thank you for coming in. Tell us how the check-up and any treatment went, and whether the final cost was what you expected. It takes about 2 minutes. This form is not an emergency service. If you need urgent medical help, call your local emergency number.
Q1.How would you rate each part of your visit?*
| Poor | OK | Excellent | Not applicable | |
|---|---|---|---|---|
| Comfort during treatment | ||||
| Pain management | ||||
| Explanation before each step | ||||
| Cleanliness | ||||
| Front-desk service |
Q2.Did the final cost match what you were told beforehand?*
- Yes
- Roughly
- No, it was higher
- I was not told a price beforehand
Q3.How anxious did you feel during treatment?
Q4.What would make your next visit better?
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