Follow-Up & Satisfaction Survey

We hope you're recovering well! This short survey helps us check in on how you're feeling and make sure everything is on track. Your honest feedback also helps us improve for all our patients — thank you for taking a few minutes to share your thoughts.

Section 1 — Visit Details

Patient's full name:

Date of your visit:

Treatment received:

Section 2 — How Are You Feeling?

What's your current comfort level?

No pain

Mild discomfort

Moderate pain

Significant pain

Are you experiencing any of the following complications?

Swelling

Bleeding

Numbness

Sensitivity

None — all good!

Please describe any issues or concerns in more detail:

Section 3 — Your Experience

Overall experience:

Excellent

Good

Fair

Poor

Staff friendliness:

Very friendly

Friendly

Neutral

Unfriendly

Wait time satisfaction:

Very satisfied

Satisfied

Neutral

Unsatisfied

Cleanliness of the clinic:

Spotless

Clean

Acceptable

Needs improvement

Section 4 — Would You Come Back?

Would you return to our clinic?

Definitely

Probably

Unsure

Would you recommend us to a friend or family member?

Yes

Maybe

Section 5 — Open Feedback

What did we do well? We'd love to hear!

What could we do better?

Any other comments or thoughts?

Thank you so much for your feedback — it genuinely helps us improve. We hope to see you again soon, and wish you a speedy, comfortable recovery!

Follow-Up & Satisfaction Survey

Section 1 — Visit Details

Section 2 — How Are You Feeling?

Section 3 — Your Experience

Section 4 — Would You Come Back?

Section 5 — Open Feedback

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