Patient Survey

Please take a moment to complete our survey.  Your comments are welcome and completely confidential. Your input will help us improve our service.  Thank you.

We appreciate you taking the time to complete our survey. Please feel free to comment on your visit as well. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.

Patient Name :
E-mail Address :
Date of your last visit:
How was the treatment you received :
How comfortable were you during the treatment you received :
Was your treatment explained to you so that you have a clear understanding of your dental situation :
Were your financial options explained to you? :
How long did you wait before being seated in a room?
Would you refer your friends and family to us? :
Please comment below on how we could make your next visit better and more comfortable.  Thank you.:


 
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New Patient Offer

 
Welcome Dental Exam $1
Includes exam, full set of xrays
and treatment consultation.
(value of $250)

 
Welcome Back Dental Exam $1
Includes exam and FMX xray
With cleaning $91.

(Must be a patient who has not been in our office within  the last two years)

 
Complete the form below by the deadline.

 
 
Offer expires: 02/08/2012
 


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Hercules Dental Care · Douglas Lin D.D.S. & Associates
500 Alfred Nobel Drive · Hercules CA, 94547

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