To service you better,we would like to know how you feel about
our dental services. We would greatly appreciate any additional
comments you feel are important. Your comments will be kept
strictly confidential.
我们非常关心您的就诊感受。您的反馈将会帮助我们改善整体服务质量，真诚的期待您的宝贵意见。（您填写的资料仅供整体分析使用，绝不做个别展示和发表）
感谢您的支持与合作！
Background Information
个人信息
· Your Email is:
邮箱地址:
· Age:
年龄
-20 21-30 31-40
41-50 50+
· Number of visits you made to the dentist's
office in the last year:
去年您拜访牙科诊所的次数
1 2 3 4 5+
· Your treatment is: Completed In Progress
您目前的治疗 已经完成 还在进行中
Please rate from
1-5 请点击您认为最恰当的选项 Very Poor 非常差(1) Poor 差(2) Fair 一般(3) Good 好(4)
Excellent 非常好(5)
1、The ease in scheduling your appointment.
预约服务快捷方便
Very Poor 非常差(1) Poor 差(2) Fair 一般(3)
Good 好(4) Excellent 非常好(5)
2、The courtesy and helpfulness of the person who
scheduled your appointment.
前台人员对您有礼貌并热心帮助您
Very Poor 非常差(1) Poor 差(2) Fair 一般(3)
Good 好(4) Excellent 非常好(5)
3、The length of your waiting time.
就诊等候时间
Very Poor 非常差(1) Poor 差(2) Fair 一般(3)
Good 好(4) Excellent 非常好(5)
4、The staff's courtesy, cooperation and level of
expertise.
医护人员的配合能力、专业程度和礼貌礼仪
Very Poor 非常差(1) Poor 差(2) Fair 一般(3)
Good 好(4) Excellent 非常好(5)
5、The dentist's efforts to provide
detailed treatment methods and respect your right to know and to
decide.
医生为您提供详细的治疗方案并尊重您的知情权和选择权
Very Poor 非常差(1)
Poor 差(2) Fair
一般(3) Good 好(4)
Excellent 非常好(5)
6、The staff's caring about any pains
you may have experienced during treatment and taking action to
minimize it.
医护人员关心您治疗中出现的疼痛，并采取有效措施预防和减少疼痛
Very Poor 非常差(1)
Poor 差(2) Fair
一般(3) Good 好(4)
Excellent 非常好(5)
7、The efficiency and painlessness of
your treatment.
整个治疗过程及时、高效和无痛
Very Poor 非常差(1)
Poor 差(2) Fair
一般(3) Good 好(4)
Excellent 非常好(5)
8、Cleanliness and presentablity of
our equipment.
治疗使用的设备及材料卫生整洁，让您放心舒服
Very Poor 非常差(1)
Poor 差(2) Fair
一般(3) Good 好(4)
Excellent 非常好(5)
9、Our promptness in complying with
your requirements and suggestions.
我们能够及时回复您的要求和建议
Very Poor 非常差(1)
Poor 差(2) Fair
一般(3) Good 好(4)
Excellent 非常好(5)
10、The overall experience of your
visit.
您在就诊过程中的整体感受
Very Poor 非常差(1)
Poor 差(2) Fair
一般(3) Good 好(4)
Excellent 非常好(5)
11、Would you recommend our clinic to
your friends and family? Yes No
您是否愿意推荐您的朋友及家人来诊所就诊 是 否
12、Please rank the following
according to their importance to you.
以下选项，请按照您的重视程度排序，请直接在文本框内顺序填写数字(1-8)
A The dentist's expertise 医生的治疗水平
B The clinic's hygiene 诊所环境及卫生状况
C Reasonable pricing 合理价格
D The cooperation among our staff 医务人员间的合作
E Courtesy and professionalism of our staff 医护人员的专业程度
F The staff's perception of your needs 医务人员对您需求的关注程度
G A painless treatment 无痛治疗过程
H The convenience of the clinic's location 诊所位置方便您就诊
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