Patient Satisfaction Survey

for ODU's Dental Hygiene Care Facility

Please rate your experience:
Please rate your experience:	Excellent	Very Good	Average	Below Average	Poor
Faculty were involved and helpful.	Faculty were involved and helpful.Excellent	Faculty were involved and helpful.Very Good	Faculty were involved and helpful.Average	Faculty were involved and helpful.Below Average	Faculty were involved and helpful.Poor
Staff were courteous and helpful.	Staff were courteous and helpful.Excellent	Staff were courteous and helpful.Very Good	Staff were courteous and helpful.Average	Staff were courteous and helpful.Below Average	Staff were courteous and helpful.Poor
Concern for my welfare was:	Concern for my welfare was:Excellent	Concern for my welfare was:Very Good	Concern for my welfare was:Average	Concern for my welfare was:Below Average	Concern for my welfare was:Poor
Student was prepared and knowledgeable.	Student was prepared and knowledgeable.Excellent	Student was prepared and knowledgeable.Very Good	Student was prepared and knowledgeable.Average	Student was prepared and knowledgeable.Below Average	Student was prepared and knowledgeable.Poor
Cleanliness of the treatment area and reception room were:	Cleanliness of the treatment area and reception room were:Excellent	Cleanliness of the treatment area and reception room were:Very Good	Cleanliness of the treatment area and reception room were:Average	Cleanliness of the treatment area and reception room were:Below Average	Cleanliness of the treatment area and reception room were:Poor
Overall, today's appointment was:	Overall, today's appointment was:Excellent	Overall, today's appointment was:Very Good	Overall, today's appointment was:Average	Overall, today's appointment was:Below Average	Overall, today's appointment was:Poor

Would you recommend this facility for preventive oral care?

Would you recommend this facility for preventive oral care? Yes No
Date of Visit Date of Visit / MM / DD YYYY
Comments
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7, 8, 9, 10 : the 2nd number is?