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SCHC Patient Satisfaction Survey – Dental

Patient Satisfaction Survey - Dental

Welcome to the Siletz Community Health Clinic (SCHC)! SCHC is committed to providing you with the best possible dental services. Your participation in this survey is extremely important and will serve as a tool to improve and enhance the SCHC Dental Clinic.

For each item identified below, circle the number to the right that best fits your judgment of the quality of service. Use the scale below to select the quality number.

Excellent = 5 Very Good = 4 Good = 3 Fair = 2 Poor = 1

Description of Services

Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.

Overall Satisfaction With:

Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.
Select the quality number on the dropdown scale.

What provider did you see today?(Required)
Eligibility Status(Required)
Gender

This field is for validation purposes and should be left unchanged.