Dental Care Survey Template

Dental Care Survey Template includes questions about the time between visits, evaluation of the visits, importance of factors in choosing a dentist, and notification preference. This sample can be edited by the survey maker according to the required details about dental care and dentists. Some of the question examples of this questionnaire are "Do you presently have a dentist that you visit on a regular basis?", "How did you find your dentist?", "The most common reason for not going to the dentist is" et al.

Dental Care Survey Template

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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 How often do you make visits to your 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 your dentist for regular 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 Text Message E-mail Other 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 Dental charges may vary subject to the amount of time that the dentist takes to complete a procedure, as well as the kind of work performed. If the cost were the same, what kind of dentist would you prefer? Takes a little longer to get the job done, but talks to you during the procedure (45 minutes time) Completes the work more rapidly and talks less (30 minutes time) Completes the work very rapidly (20 minutes time) Would you expect the dentist who takes longer to do a better job? Yes No Not sure What do you like best about your personal dentist? What would you suggest that might make a visit to your dentist more pleasurable?