Survey – Daydreams PC

Date of Surgery *

Month Day Year

Was this your first visit to Daydreams Procedure Center?

Yes No

Name of Dentist in charge of your child’s care

Please rate the services you received with a check in the appropriate box.

	Excellent	Good	Fair	Poor	N/A
Surgical procedure was discussed clearly prior to the event
The phone call to prepare for surgery was helpful
Billing and insurance questions were answered clearly
The facility was comfortable and organized
The facility was convenient
The facility staff was corteous and efficient
The staff was available to answer questions and explain procedures
Anesthesiologist’s explanation was clear and questions answered
Post-surgery instructions were explained clearly
Staff concern for privacy

What did you like about Daydreams?

Were there any problems you did not anticipate?

How might we improve?

How did you find out about Daydreams?

Would you tell others about Daydreams?

Would you like to be contacted?

Yes No

Name

First Name Last Name

Phone Number

Please enter a valid phone number.

It would help us to know…