My Family Dental Care
My Family Dental Care

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Enter survey and receive a “Free Oral hygiene kit”

Welcome to the Myfamilydentalcare family!

We thank you for choosing our office and hope that find our services valuable.

In order to provide continuous quality care for all our patients, we would appreciate your input. Your answers are confidential; we will not disclose them to a third party.

At the end of the Survey you may choose to Print a receipt or Email receipt to be printed later. You will be required to show a printed copy of your confirmation at your respective office to collect your Free Oral Hygiene kit.

Thank you in advance for your response. 

 

DENTAL SERVICES SURVEY

In order to provide continuous quality care for all our patients, we would appreciate your input. Your answers are confidential; we will not disclose them to a third party. Thank you in advance for your response!

1. Is this your first visit in our office?
Yes No. I am a returning patient
2. How did you hear about us?
Family or Friends Yellow Pages/ Phone Directory
Outdoor Advertising (Posters, Billboards) From my Insurance
Newspaper or Magazine Advertisement Web search / Internet
Other
If Other, Please specify
3. How far did you travel to see our dentist?
Less than 5 miles 6%u201410 miles More than 10 miles
4. Do you carry Dental Insurance?
Yes No. Go to question 7
If Yes, Please specify which one
5. How did you obtain the Insurance?
Through Employer I qualified for MEDICAID / MEDICARE I purchased on my own
Other
If Other, Please specify
6. Are you satisfied with your current Insurance Plan?
Very satisfied; I would not change anything. Not satisfied; I am looking to change my plan Somewhat satisfied
If not Satisfied, Please specify all you are not pleased with (check all that apply)
The copayment The pre-existing condition clause
The yearly maximum limit Preauthorization required
Other
If Other, Please Specify
7. Your Gender:
Male Female
8. Age group
- 20 21-30 31-50
51-65 65 -
9. Number of members in your family
Of which, number of Children are
10. Family Income per year
Less than $50,000 $50,000-$75,000 $75,001-$100,000
Over $100,000
 
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My Family Dental Care
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