155 N. Umpqua, Sutherlin, OR 97479
Call Today: (541) 459-2882

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   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 (optional):
E-mail Address (optional): 
Date of your last visit (optional):
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

Free New Patient Exam and Panorex.

Offer Expires
05/24/2013

Complete the form below or call our office to take advantage of this offer!

 
Sutherlin Dentist · Donald Randol, DDS · 155 N. Umpqua · Sutherlin, OR · 97479
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