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Hello:

You are invited to participate in our survey [Project Description Here]. In this survey, approximately [Approximate Respondents] people will be asked to complete a survey that asks questions about [General Survey Process]. It will take approximately [Approximate Time] minutes to complete the questionnaire.


Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.


Your survey responses will be stricly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.


Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
 

* Gender?
 
Female
 
Male
 

* How old are you?
 
16 to 20
 
21 to 30
 
31 to 40
 
41 to 50
 
51 to 60
 
61 and above
 
 
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
 
 
 
Since when have you made regular visits to the 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 the dentist for 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
 
E-mail
 
Other
 
 
 
 
If two weeks go by and you had not yet made an appointment, would you like them to call back again?
 
Yes
 
No
 
Not sure
 
 
 
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
 
 
 
 
Would you expect the dentist who takes longer to do a better job?
 
Yes
 
No
 
Not sure
 
Please contact [email protected] if you have any questions regarding this survey.
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