3740 N. Josey Lane
Suite 121 Carrollton, TX 75007
(972) 492-2866

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Postoperative Instructions

Tooth Extractions
Composite Fillings
Crowns & Bridges
Nightguards
Root Canal Treatment
Porcelain Veneers
Gum Surgery
Dentures and Partials

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Learn more about PerioLase

PerioLase Revolutionizes Gum D i s ease Treatment!

Patient Survey

Name:
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How would you rate your overall visit?

Excellent Very Good Average Not so good

When your appointment was over did you have a good understanding of your dental situation?

Yes Not really I wish I knew more about my situation

Were your financial options explained to you?

Yes No I already understand my financial options

Did you have to wait over 15 minutes past your appointment time to be seated? If so how long?

No 15 - 30 minutes 30 - 45 minutes Over 45 minutes

Did the staff greet you properly?

Yes Not really I don't recall

Would you refer your friends and family to us?

Yes No I'm not sure Comments:

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Preferred time of day

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©2011 Ron Proctor, DDS

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