1. Were you able to schedule an appointment at a time convenient for you?  Yes       NO Additional Comments 2. How did you make your appointment?  By phone        In-Person        Website 2a. If the appointment was made by phone, was the call pleasant?  Yes        NO Additional Comments 3. Were you able to print out forms from our website?  Yes        NO 3a. Did you find that convenient?  Yes        NO Additional Comments 4. Was our reception area comfortable and pleasant?  Yes        NO Additional Comments 5. How were you referred to our office?  Friend        Dentist        Website        Other Additional Comments 6. May we thank the person who referred you to us?  Yes        NO Name Address 7. Did our staff make you feel comfortable and relaxed?  Yes        NO Additional Comments 8. Was your procedure explained to your satisfaction?  Yes        NO Additional Comments 9. Was the explanation of payment information to your satisfaction?  Yes        NO Additional Comments 10. The quality of treatment you received from Dr. Saint-Cyr was. 1 2 3 4 5 6 7 8 9 10 Average Excellent Additional Comments 11. The level of courtesy and respect you received from the staff was 1 2 3 4 5 6 7 8 9 10 Average Excellent Additional Comments 12. Would you recommend this office to a friend, relative or colleague?  Yes        NO Additional Comments 13. What can we do to enhance your experience? 14. Would you return to Infinite Endodontics if you needed another appointment?  Yes        NO Additional Comments Optional Information: Name: Phone: Email:

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