Questionnaire about dental treatment from San Diego Cosmetic Dentist

FREE Consultation


760-942-0800


Contact Us

Name:  
Phone:
Email:   
Questions / Comments






Dental Videos

Patient Survey

In order for Dr. Fallah's Office to better service your dental needs, please kindly share with us your feelings and experiences concerning your most recent visit by filling out this survey.  When you have completed it, please press the Submit button at the bottom of the form.  Thank you in advance for your assistance.

Background Questions

Please indicate all of the services that you have received within the last 12 months.

Cosmetic
Cleaning
Restoration
TMJ
Emergency Care
Extractions 		Implants
Dentures
Braces

Please indicate your answers to the following based on your last visit with us.

Visit Date:      Visit Time:
Was this your first time visiting our practice? Yes No
Did the dentist examine you on your visit? Yes No
Did you experience any discomfort during your treatment? Yes No
Did someone review your medical history? Yes No
Did someone discuss with you the various types of services that we offer our patients? Yes No
Are you currently covered by dental insurance? Yes No
What is your main source of payment? Self-Pay
Preferred Provider
Private Insurance

Opinion Questions

Please indicate your view on your overall experience with our office and staff.

Very Poor

Poor

Fair

Good

Very Good

Comfort of the lobby/waiting area

Cleanliness of facilities

Front desk staff's attentiveness to your needs

Assisting staff's attentiveness to your needs

Hygienist's attentiveness to your needs

Doctor's attentiveness to your needs

Clear explanation of treatment options

Availability of payment options

Helpfulness of the staff scheduling your appointment

Length of time between calling for an appointment and being examined

Convenience of office hours

Timeliness of appointment

Teamwork exhibited by our dental team

Thoroughness of exam and treatment

Friendliness of the dental assistant

Professionalism of the dental assistant

Professionalism of the dental hygienist

Oral hygiene education provided by the hygienist

Equipment & facilities modern & up-to-date

Overall rating of care provided

Likelihood of recommending our practice to others

If you are happy with our services please tell your loved ones and friends, and if you were dissatisfied for any reason please tell us so we can respond to any issue.

Additional Comments / Testimonial

You Can Publish My Comments Below as a Testimonial --    Yes     No

For Publication You Can Use the Following Name or Initials (optional) --

Please provide any additional feedback regarding our office and staff (or testimonial) below.


Referrals


Can you give us any email referrals? For each one you will be entered to win a prize at our monthly drawing.


Thank you for taking the time to fill out this survey.

  













Dr. Fallah, DDS, FICCMO
Doctor of Dental Surgery
Fellow of International College of Cranio-Mandibular Orthopedics
Holistic Dentist
 1200 Garden View Rd., Suite 108
Encinitas, CA 92024
Phone: (760) 942-0800


Dr. Fallah's Holistic Dental Clinic serves all of Southern California, San Diego County and the local communities of Carlsbad, Encinitas, Cardiff, San Marcos, La Costa, La Jolla, Coronado, Rancho Santa Fe, Solana Beach, Del Mar, Oceanside, Leucadia, Olivenhain, Fairbanks Ranch, Carmel Valley, 4S Ranch, Rancho Bernardo -- Zip Code -- 92007, 92008, 92009, 92010, 92011, 92014, 92023, 92037, 92038, 92039, 92067, 92075, 92078, 92091, 92092, 92093, 92118, 92121, 92127, 92128, 92129, 92130, 92137, 92178 -- Phone Area code: 858, 760, 619



Back