Patient Survey

In order that we may better serve your needs, please share your findings concerning your visit with us. When you have finished, please press the submit button at the bottom of the screen. We thank you in advance for helping us in our commitment to Constant And Never-ending Improvement.

THE SERVICES YOU RECEIVED

Please select the services you received in the last 12 months.

Cleaning
Periodontal Care
Extractions

Emergency Care
Restoration
Cosmetic

Dentures
Implants
Braces

BACKGROUND QUESTIONS

Date of Visit: Time of Visit:

Was this the first time you have used our practice?	Yes No
Did you see the dentist on every visit?	Yes No
Did someone review your medical history?	Yes No
Are you covered by dental insurance?	Yes No
Were you informed about the type of services we offer	Yes No
Were you in any discomfort during your treatment?	Yes No

Main source of payment: Self-Pay Private Insurance Preferred Provider

MISCELLANEOUS

	Very Poor	Poor	Fair	Good	Very Good
Comfort of the greeting area
Cleanliness of facility
Equipment / Facility modern & up-to-date
Front desk staff concern for your needs
Assisting staff attention to your needs
Hygienist attentive to your needs
Doctor attentive to your needs
Options for treatment clearly explained
Availability of payment options
Likelihood of recommending us to others
Overall rating of care provided
Length of time between calling for an appointment and being seen
Helpfulness of the person scheduling your appointment
Convenience of hours
Appointment timeliness
Teamwork shown by dental team
Thoroughness of exam and treatment
Friendliness of the dental assistant
Professionalism of the dental assist
Professionalism of the Hygienist
Education provided by the Hygienist on oral hygiene

Comments (describe good or bad experience):

Thank you for taking time to give us your valuable opinion. Our passion is extending “Legendary Hospitality” to you… our extended family.

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Dr. Shreyesh Ruparelia is a cosmetic dentist in Sterling near Washington DC. Services offered at Cascade Center for Dental Health include invisalign,tooth whitening, veneers, and laser dentistry. Proudly serving Sterling, Herndon, Virginia, and Washington DC communities.