Appliance Satisfaction Survey

Dr. Name / Clinic *

Patient Name or Case # *

Phone *

Email Address *

Model Type Model Type Stone Model Digital Scan

Overall band/crown fit? Overall band/crown fit? Unacceptable Unsastificatory Satisfactory Excellent Outstanding

Overall Acrylic Trim/Thickness/Color or design? Overall Acrylic Trim/Thickness/Color or design? Unacceptable Unsastificatory Satisfactory Excellent Outstanding

Overall Wire and/or Clasping? Overall Wire and/or Clasping? Unacceptable Unsastificatory Satisfactory Excellent Outstanding

Overall Appliance Satisfaction? Overall Appliance Satisfaction? Unacceptable Unsastificatory Satisfactory Excellent Outstanding

Prescription and/or Preferences followed? Prescription and/or Preferences followed? Yes No

Would you like a customer service representative to call and set up custom appliance preferences? Would you like a customer service representative to call and set up custom appliance preferences? Yes No

Additional comments/feedback: