Patient Surveys

This survey provides you the opportunity to tell us objectively how we are doing.

Dr. Azar-Mehr and her Orthodontic team continually strive to give patients and their families the very best care. We value your comments and suggestions so we can provide you the best possible Orthodontic experience.

We believe great communication with our patients is important. Please help us serve your needs by taking a few minutes to complete this survey. It will be used as a resource in our continuous service development program.

1) Tell us about yourself

1. What is your relationship with our office?

 Patient   Mother   Father
Other Relationship (please specify)

2. Do you have other family members in treatment?

 Yes   No

3. What is your age group?

 Adult   Teen   Youth (under 12)

4. Survey participant name:

 Your Name

*Note: If you would like a response to your concerns or comments, please include your name and the name of the patient so we can send you a letter. If you prefer an online reply please include your email address.

 Patient name if different than your name


Email address


2) Please rate the following and provide us with any comment that may help us improve our service to you.

1. Phone courtesy

          

2. Phone promptness

          

3. The manner in which our staff greets

          

4. Courtesy of our staff

          

5. Computer sign-in

          

6. Promptness in being seen for your appointment

          

7. The overall appearance of our office

          

8. Office cleanliness

          

9. How comfortable do you feel in the office

          

10. Neatness of staff appearance

          

11. Appointment scheduled conveniently

          

12. Politeness of appointment secretary

          

13. Thoroughness of appointment secretary

          

14. How prompt was Dr. Azar-Mehr in seeing you

          

15. Thoroughness of Dr. Azar-Mehr evaluation

          

16. How well do we respond to your emergencies

          


3) Please fill in the blanks to these questions

17. How long do you usually wait in our reception room before being seen

18. What is your opinion of the amount of time doctorspent with you at the chair

19. What do you like most about our office


4) Please select Yes or No

20. Are you aware of our Refer-A-Friend contest

 Yes   No

21. Are you aware of our good cooperation contests to reward patients

 Yes   No

22. Do you feel our office has an inviting and comfortable atmosphere

 Yes   No

23. Are you aware of our "Family Care Program" and our desire to see other children in the family by the age of seven for a complimentary exam

 Yes   No

24. Are you aware we have gold brackets available

 Yes   No

25. Are you aware we have clear crystal brackets available which are nearly invisible

 Yes   No

26. Are you aware we have the latest colors in rubber bands and braces

 Yes   No

27. Are you aware of the cosmetic and health effects Orthodontics can create for adult patients

 Yes   No

28. Are you aware we offer treatment progress updates at the chair during regularly scheduled office visits

 Yes   No

29. Are you aware we use the latest state-of-the-art sterilization methods

 Yes   No

If we could change one thing about our office, what would you suggest?

Additional Comments

Thank you for your insight and participation. We really appreciate you choosing our office! We are committed to quality and patient satisfaction and hope that you will feel confident in referring your family and friends.

After you submit this form, you will be presented with a confirmation page to acknowledge we have received your survey responses.

Survey responses are sent directly to the Office Manager, Shirley Merz.

 Patient Surveys
9535 Reseda Blvd.
Suite 206
Northridge, CA 91324

Ph: (818) 886-6666