Dental Care Survey Template

Dental Care survey including time between visits, evaluation, importance of factors in choosing a dentist, and notification preference.


   
 
Do you presently have a dentist that you visit on a regular basis?
 
Yes
 
No
 
   
 
How did you find your dentist?
 
Referral by friend/neighbor
 
Referral by acquaintance
 
Referral by another dentist
 
Referral by doctor
 
Advertisement
 
Phone book
 
Saw office/sign
 
Other
    
 
   
 
Do members of your household go to (check all that apply):
 
One dentist
 
More than one dentist
 
An orthodontist
 
An oral surgeon
 
Other dental specialist
 
Other
    
 
   
 
The most common reason for not going to the dentist is:
 
I do go for regular check-ups
 
Transportation
 
The cost of care
 
I don't need to go very often
 
I forget to go
 
I don't like dentists
 
There is nothing wrong with my teeth
 
Other
 
   
 
How often do you make visits to your current dentist?
 
< 6 months
 
6 months - 1 year
 
1-2 years
 
2-3 years
 
3-4 years
 
4+ years
 
   
 
How often do you go to your dentist for regular checkups?
 
Every 6 months
 
At least once a year
 
At least every 2 years
 
At least once every 3-4 years
 
It depends, I go when I have trouble with my teeth
 
   
 
Would you like your dentist to notify you when it is time for a 6-month check-up?
 
Yes
 
No
 
Not sure
 
   
 
If you would like your dentist to notify you when it is time for a check-up, how would you prefer to receive this notice?
 
Phone call
 
Mail
 
Text Message
 
E-mail
 
Other
    
 
   
 
I would prefer the following payment plan for my dental care:
 
Payment required at the time of care (cash/check)
 
Payment by charge cards at the time of care (VISA, Mastercard, etc.)
 
Monthly payment plan at 1.5% interest per month
 
Payment due within 30 days
 
Other
    
 
   
 
Dental charges may vary subject to the amount of time that the dentist takes to complete a procedure, as well as the kind of work performed. If the cost were the same, what kind of dentist would you prefer?
 
Takes a little longer to get the job done, but talks to you during the procedure (45 minutes time)
 
Completes the work more rapidly and talks less (30 minutes time)
 
Completes the work very rapidly (20 minutes time)
 
   
 
Would you expect the dentist who takes longer to do a better job?
 
Yes
 
No
 
Not sure
 
   
 
What do you like best about your personal dentist?
   
 
   
 
What would you suggest that might make a visit to your dentist more pleasurable?
   
 

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