Palmdale Dentist - Patient Survey

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	SIX MONTH SMILES
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Patient Survey

Please take a moment to complete our survey. Your comments are welcome and completely confidential. Your input will help us improve our service. Thank you.

We appreciate you taking the time to complete our survey. Please feel free to comment on your visit as well. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.


Patient Name :
E-mail Address :
Date of your last visit:
How was the treatment you received :
How comfortable were you during the treatment you received :
Was your treatment explained to you so that you have a clear understanding of your dental situation :
Were your financial options explained to you? :
How long did you wait before being seated in a room?
Would you refer your friends and family to us? :
Please comment below on how we could make your next visit better and more comfortable. Thank you.: Please enter code above in the field below.

New Patient Offer

Six Month Smiles
$500 Off Any New Case
Free Consultation

Sedation
Now 50% Off

Free Bleaching
or $50 Gas Card
(with New patient cleaning,
x-rays and exam)
-Limit 2 per Family-

Offer Expires: 02/09/2012

<div style="text-align: center"><span style="color: rgb(255,0,0)"><strong><span style="font-size: medium"><br />
</span><span style="font-size: large"><span style="color: rgb(255,0,0)">New Patient Offer</span></span></strong></span><strong><span style="font-size: medium"><br />
</span></strong></div>
<div style="text-align: center"> </div>
<div style="text-align: center"><strong>Six Month Smiles</strong><br />
$500 Off Any New Case<br />
Free Consultation<br />
 </div>
<div style="text-align: center"><a target="_blank" href="/Simmons-Gift-Certificate.pdf"><img border="1px;" border-color="black" alt="Give the gift of health" src="/images/Gift-Cert-Small.jpg" /></a><br />
<br />
 </div>
<div style="text-align: center"><strong>Sedation</strong><br />
Now 50% Off<br />
 </div>
<div style="text-align: center"><strong>Free Bleaching <br />
or $50 Gas Card</strong><br />
(with New patient cleaning, <br />
x-rays and exam)<br />
<span style="color: rgb(128,0,0)">-Limit 2 per Family-</span><br />
<br />
<span style="color: rgb(255,0,0)">Offer Expires:</span>  02/09/2012<br />
<br />
<br />
 </div>

Please enter code above in the field below.

Palmdale Dentists · Simmons Dental Care · 1029 Elizabeth Lake Road · Palmdale, CA · 93551