AdminDENPLAN Feedback Form - Draft example

(Please tick the appropriate box below)     Ideal      Acceptable Unacceptable
Q1 How would you describe the general level of comfort and freedom from pain in your mouth?                    
Q2 Generally, and as far as your teeth and mouth are concerned, how would you describe your ability to eat just about anything you like?                    
Q3 Generally, how would you describe the appearance of your teeth (including any false teeth)?                    
Q4 How would you rate the competence of your dental team?                    
Q5 How would you rate the standard of cleanliness and hygiene at your dental practice?                    
Q6 How would you describe the attitude of the dental team towards you?                    
Q7 How would you rate the ability of your dental team to understand your needs?                    
Q8 How would you rate the ability of the dental team to explain things to you?                    
Q9 How would you describe the value for money given by your dental practice?                    
Q10 How would you rate the level of trust that you feel in your dental team?                    
Q11 How do you rate the service offered by the dental team?
Excellent Good Fair Poor Unacceptable
Q12 How likely is it that you would recommend your dental practice to a friend or colleague? Score
(Please give a score out of 10, where 0 = Not at all likely and 10 = Extremely likely.)
Q13 Please tell us one thing which could be improved about your dental practice. (please write in below)
Q14 What do you like best about your dental practice? (please write in below)

Q15 Please indicate your regular dentist.
Q16 What type of patient are your? Q17 Are you:
Denplan Private-fee-per-item NHS Male Female
Q18 What is your age (or the age of the child your are responding on behalf of?)
5 or younger 6-11 12-18 19-34 35-54 55+

I wish to remain annonymous
I wish to provide my details (this is especially useful if you would like the practice to contact you with regards to your feedback.)
Email: Phone/Mobile:
Can we use your feedback as a testimonial? Yes: No: