212-697-1701       121 East 60th Street Suite 1B  New York, NY  10022
Personal Dental Needs Survey
  1. smileslogo

    121 East 60th Street Suite 1B    New York, NY 10022     Tel: (212)697-1701  Fax: (212)755-2747  www.smilesparkavenuedental.com

  2. Your Name(*)
    Please let us know your name.
  3. Your Email(*)
    Please let us know your email address.
  4. Date(*)
    Please enter the date.
  5. Please rate on a scale of 1-5 the importance of each of the following regarding your dental care. (The most important would be #1).
  6. Preventive dental health care (*)
    Choose One
  7. Freedom from pain (*)
    Choose One
  8. Excellence and quality of service(*)
    Choose One
  9. Cost and Affordability(*)
    Choose One
  10. Other
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  11. Please rate, as above, what a dentist has to do to gain your confidence
  12. Show me what he/she is doing or needs to do so I can clearly understand what is happening. (*)
    Choose One
  13. Listen to my concerns and explain thoroughly the procedures to be performed.(*)
    Choose One
  14. Make sure I feel comfortable and informed at all times.(*)
    Choose One
  15. Please check the level of fear you have about dental visits (10 being the greatest fear)
  16. What is your level of fear? (*)
    Choose One
  17. I would like to know about these options available to me for maximizing my comfort and my experience during my visit. (Check all that apply).
  18. How can we maximize your comfort?
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  19. Are you concerned about the following? (Select All That Apply)
  20. Check all your concerns that apply?
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  21. If other, what is your concern?
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  22. Please Chose one selection.
  23. When discussing my treatment plan, I prefer:
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  24. When evaluating my smile, it’s most important:
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  25. What would make you choose our dental office over another?
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  26.   

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