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Patient Survey

Please take a moment to complete our survey.  Your comments are welcome and completely confidential. Your input will help us improve our service.  Thank you.

We appreciate you taking the time to complete our survey. Please feel free to comment on your visit as well. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.

Patient Name :
E-mail Address :
Date of your last visit:
How was the treatment you received :
How comfortable were you during the treatment you received :
Was your treatment explained to you so that you have a clear understanding of your dental situation :
Were your financial options explained to you? :
How long did you wait before being seated in a room?
Would you refer your friends and family to us? :
Please comment below on how we could make your next visit better and more comfortable.  Thank you.:


 
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New Patient Offer

Receive a Cleaning, Exam
and X-rays for only $99

or

Receive $350.00 off
a porcelain crown or veneer

Complete the form below to
take advantage of either
amazing offer.

Offer Expires:  
07/31/2010


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Park Avenue Dentistry · 316 Park Avenue North · Winter Park, Florida · 32789
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