PATIENT SURVEY
	At SUNNYVALE DENTAL CARE, we strive to offer the very best in patient care. In order to provide that care we turn to our patients for advice. Please take a moment to complete the patient survey below. We thank you in advance for your time and participation. The information below is confidential, and will only be used to improve our service.
	1st Visit   Repeat patient (skip to #3)  1.   Was this your first visit to our office or have you been here before? 2.   If you answered "1st Visit," how did you hear about us? Someone referred me A mailer that came to my house An Internet search Yellow Page Ad Radio Ad Television Ad Ad in local newspaper An Insurance Referral Don't remember Other (please specify) Other:  3.   What was the purpose of your visit? Cleaning , exam, x-rays Restorative Dentistry Emergency Dentistry Consultation   On a scale of 1 to 5, with 5 being "Great," how would you rate your experience on your last visit? If a particular line does not apply to your visit, please skip it.  Poor   Fair   Okay   Good   Great  4.   Cleanliness/neatness of the waiting room 5.   Friendliness of our office staff 6.   Friendliness of the dentist   If you would like to provide us with your contact information please use the boxes below: 7.   Name: 8.   Phone Number: 9.   Email Address: