Elm Endodontics Patient Survey

Q.1

When you made your appointment, how did the front ofﬁce personnel make you feel about your future visit?

More comfortable about my future visit.
No different about my future visit.
Less comfortable about my future visit.

Q.2

Which of the following was your greatest concern about being referred to our office?

How much time (or how many visits) would be required
Potential pain of the procedure
There were no concerns
Cost of treatment
Other:

Q.3

Which of the following best fits how you feel about your in-office waiting period before being seen by Dr. Shelley?

I had to wait too long.
I did not have to wait.
I had to wait but it was acceptable.

Q.4

Please rank the administration of local anesthesia (numbing agent).

Simply put, how was it when you received "the shot"?

More painful than I expected.
Less painful than I expected.
Painless
About what I expected.
None was administered.

Q.5

Think for a moment about your comfort level during the actual root canal treatment, the period after the anesthetic (numbing agent) was administered. How would you describe your comfort level during the root canal procedure?

Painless
Mostly painless
Somewhat painful
Very painful

Q.6

How many days has it been since you received treatment?

1 Day
2 Days
3 Days
4 Days
More than 4 days

Q.7

Where would you rate the level of pain you had prior to initiation of treatment?

0 = no pain, 10 = worst imaginable

The pain was a:

Q.8

Please rate the comfort of your tooth now.

Totally comfortable. No symptoms.
Mildly uncomfortable and getting better.
Moderately or severely uncomfortable and getting better.
Moderately or severely uncomfortable and staying that way or getting worse.

Q.9

Are you taking pain medications for the tooth at this time?

Yes
No

Q.10

What are your thoughts about the length of your treatment appointment?

It was longer than I thought it would be.
It was shorter than I thought it would be.
It was about what I thought it would be.

Q.11

When did you become aware of the cost of your treatment?

Before my arrival.
After my arrival, but before the treatment was started.
After treatment was started, but before it was completed.
After treatment was completed.
I am not yet aware of my cost for the treatment.

Optional Comments:

Q.12

How likely are you to refer people you know to our office?

Highly likely.
Somewhat likely.
Somewhat unlikely.
Highly unlikely.

Q.13

What could have been done to improve your root canal experience?

Optional Comments:

You're almost finished!

When you press the blue "Finish Survey" button below, you'll be taken to a page where we would love it if you'd submit a review. Thanks for your consideration.