Root canal therapy
Root canal re-treatment (redo of an old root canal)
Apical surgery (root canal surgery)
Consultation

	1		4
	1	2	3	4
Number of visits

	Expensive					Inexpensive
	1	2	3	4	5	6	7	8	9	10
Cost

	Time-Consuming					Quick
	1	2	3	4	5	6	7	8	9	10
Time

	Painful					Pain Free
	1	2	3	4	5	6	7	8	9	10
Pain

	Unpleasant					Pleasant
	1	2	3	4	5	6	7	8	9	10
Pleasantness

	Very Dissatisfied					Very satisfied
	1	2	3	4	5	6	7	8	9	10
TREATMENT

If you were not completely satisfied with the TREATMENT
what changes do you feel would have improved your experience?

	Very Dissatisfied					Very Satisfied
	1	2	3	4	5	6	7	8	9	10
INITIAL PHONE CONTACT

	Very dissatisfied					Very Satisfied
	1	2	3	4	5	6	7	8	9	10
FRONT DESK at CHECK-IN

	Very dissatisfied					Very satisfied
	1	2	3	4	5	6	7	8	9	10
IINSURANCE BILLING/FINANCIAL ARRANGEMENTS

Yes
No
Don't know

How did you find out about our office?

	0	1	2	3	4	5	6	7	8	9	10
Dentist's recommendation
Endodontist is on my insurance's network
Ease of obtaining an appointment
Knowledgeable receptionist
Office accessibility and location
Other

Yes, I will preemptively recommend your office to my general dentist/another patient.
I will recommend only if they ask