PATIENT SURVEY
	At Capstone 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.
	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  1.   Greeting by our receptionist when you arrived 2.   Cleanliness/neatness of the waiting room 3.   Cleanliness/neatness of the operatory 4.   Friendliness of our office staff 5.   Friendliness of the dentist 6.   Quality of the service performed 7.   The ease of checking out and paying after the appointment 8.   In your own words, let us know any issues or concerns you may have about our services or office practices and procedures.    Poor   Fair   Okay   Good   Great  9.   How likely is it that you would recommend our dental office to your family members, co-workers, and friends?   If you would like to provide us with your contact information please use the boxes below: 10.   Name: