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Patient Survey
Please complete all the required fields marked in red below.
Please Take Our Patient Survey!
At the end of the survey you will receive a discount off your next service.
Last visit to Kakaris Family Dentistry
Was this your first visit?
Yes
No
If yes, how did you hear about Kakaris Family Dentistry?
Magazine/Newspaper Article
Radio
Billboard
Other
What was your overall perception of the Kakaris Family Dentistry office and staff?
Did the environment and staff make you feel comfortable?
Very Uncomfortable
Uncomfortable
Neither
Comfortable
Very Comfortable
Do you feel that the doctor/hygienist spent enough time with you so you had a good understanding of your dental situation?
Yes
No
Do you have any questions about your billing that were not answered by the staff?
Yes
No
Have you been thanked by the staff for your visit?
Yes
No
Please complete all the required fields marked in red below.
Please rate how satisfied you were with your over-all visit:
Very Unsatisfied
Unsatisfied
Neither
Satisfied
Very Satisfied
Have you ever considered any type of cosmetic dentistry? What type?
No
Invisalign(TM)
Veneers
Same Day Crowns
Whitening
Snap-on Smile
Lumineers
Porcelain Crowns
Porcelain Veneers
Bonding
Do you or someone you know have trouble sleeping?
Yes
No
Do you know that Dr. Kakaris is available 24/7 for emergencies?
Yes
No
Do you feel comfortable recommending Dr. Kakaris to friends and family?
Yes
No
Would you provide a name and e-mail address so we can contact them?
Full Name
E-mail Address
We are doing some advertising in your area - have you seen the ads?
Yes
No
Where?
Newspaper
Magazine
Radio
Billboard
N/A
What is the best way to communicate new services or current specials?
Email
Phone
Mail
What is Sleep Apnea?
Office Hours
Monday
8 am–6 pm
Tuesday
8 am–7 pm
Wednesday
9 am–6 pm
Thursday
8 am–7 pm
Friday
9 am–1 pm
Saturday
9 am–3 pm
Exceptions May Occur
(888) 318-9931
(734) 676-1656