Experience Form A smile is a curve that sets everything straight. Phyllis Diller Amazing Dental Care Patient Experience Rev 1 Please help us by providing your name: (required) How would you rate your overall experience with Amazing Dental Care? (required) 12345678910 What made your experience "Amazing"? We would like to share your comments with future potential patients. We will use only your first name and first letter of your last name and no contact information. (required) Approximate date of your most recent visit to Amazing Dental: Was this your first visit to Amazing Dental? How many visits have you had to Amazing Dental in the last 12 months? How likely are you to recommend Amazing Dental Care to your family, friends, neighbors, or in general conversations? 12345678910 Have you recommended Amazing Dental to a friend or relative? Did you use our transportation service? How did you learn about Amazing Dental Care? (Select all that apply.) Please provide us with the name of the person who referred you. We want to thank them! Please rate the importance of each factor in your decision to obtain dental services from Amazing Dental. Quality of dental services Very ImportantImportantNot Important Cost of dental services Very ImportantImportantNot Important Transportation Very ImportantImportantNot Important American-owned Very ImportantImportantNot Important Ease of access across border Very ImportantImportantNot Important Ease of scheduling treatment(s) Very ImportantImportantNot Important Company's 13 years in business Very ImportantImportantNot Important Two year warranty on procedure Very ImportantImportantNot Important Discount for military and first responders Very ImportantImportantNot Important Is there a specific Amazing Dental employee who deserves special recognition for a job well done? Do you live at least part of the year in a 55+ Community? In which city is your 55+ Community located? Please provide the name of your 55+ Community. Δ
