Terre Haute Dentist

Patient Survey



	HOME
	SMILE GALLERY
	ABOUT DR. ANSHUTZ
	SMILE MAKEOVER
	TEETH WHITENING
	INVISIBLE BRACES
	HOURS & LOCATION
	PATIENT SURVEY
	COSMETIC ANALYSIS
	PATIENT TESTIMONIALS
	FINANCE OPTIONS
	PATIENT EDUCATION
	LINKS
	CONTACT US

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.

Send us an email message via this form.

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

Receive $100.00 OFF Teeth Whitening!

or

Refer-a-Friend and receive a $50.00 Credit on your account. The person you refer to us will also receive a $50.00 Credit on their account.

or

Receive $100.00 OFF any Cosmetic or Restorative Dental Treatment.

Please specify which offer you prefer in the form below.

Offer Expires: 03/19/2010