Email Usage Survey

We have recently instituted email capabilities for all our restorative doctors, hygienists and business staff. We believe email is an effective means of communication for many issues, and in some instances is easier and more effective than a phone call. We would like to know how you currently use email, and your thoughts on how we may use email to enhance our communication with you.

Please take a few minutes to complete this survey of email usage. Note that all fields in the first two section must be answered in order to submit this form.

The information you provide in this survey is considered part of your confidential medical record, and is not available to anyone outside our office.

Your assistance is greatly appreciated.
If you are not currently a patient, please return to the main site.

Thank you
The Doctors and Staff

Section 1 Personal Information
(all fields are needed to submit survey)
First name:
Last name:
Address:
City, State, Zip:
Home Phone (xxx-xxx-1234)
Email address
What is your age?: What is your gender?

Section 2 How do you use email?
(all fields required to submit survey)
How frequently do
you check your email?:
Which email
account do you use
most frequently?:
What email program
do you use?:
How would you rate the
value of our
email capabilities?
Section 3 How would you like us to use email?
(please answer as many as possible)
Click check box if "Yes"
Answer treatment questions Respond to billing and insurance issues
Accept appointments requests
Provide appointment confirmation
Provide meaningful information on
dental health topics		 Provide email contact with
doctors and hygienists:
What other uses could
you forsee using email for?