Patient Cancellation Survey

At Creve Coeur Dental we are constantly trying to improve the services we deliver to our existing and potential patients. Please take a moment to rate each item,

1= least influenced my decision to cancel  … 5=most influenced my decision to cancel, for why you canceled your appointment with us.

Your Feedback is Important to us and does help make our office a better place for out patients and staff.

Your Name (required)

Your Email (required)

 

KEY: 1=Least influenced, 5=Most influenced

 

Prices / Money Issues
12345

 

Not In Network with your insurance company
12345

 

Forgot about appointment
12345

 

I was not contacted for the appointment
12345

 

I have a Fear of the Dentist / Dental Procedures
12345

 

I was influenced by something I read or heard about the practice
12345

 

I went to a different office because of interaction with staff or doctor
12345

 

I went to a different office because of location
12345

 

I went to a different office because of price
12345

 

Emergency Visits Only --- I was uncomfortable with paying in full and having my insurance company reimburse me. (if you were not scheduled during emergency hours, please mark 1).
12345

 

Additional Comments