Member Satisfaction Survey Questionnaire  
Please indicate your response by checking the ‘Yes’ or ‘No’ box  
Yes  
No  
1
2
3
Did you feel comfortable discussing treatment with your office?  
Were you treated with courtesy and respect during your visit?  
Would you recommend this dental office to your family and  
friends?  
Under 10  
Minutes  
10-20  
20-30  
Over 30  
Please indicate your response by checking the  
appropriate box  
Minutes Minutes Minutes  
4
How long was your in-office wait time?  
Very  
Somewhat  
Not  
Satisfied  
Please indicate your response by checking the  
appropriate box  
Satisfied Satisfied Satisfied  
5
How would you rate your ability to make an  
appointment within a reasonable time?  
How would you rate the professionalism of  
6
the office staff?  
How would you rate the cleanliness of the  
7
office?  
8
How would you rate the treatment/services  
you received?  
How would you rate your overall satisfaction  
9
with the office?  
0
Overall Experience  
1
The following information is optional  
Name:  
___________________________________  
___________________________________  
___________________________________  
Telephone Number:  
E-mail:  
Completed forms should be sent to:  
LIBERTY Dental Plan  
PO Box 26110  
Santa Ana, CA 92799-6110