After Treatment Questionnaire

Please indicate below whether you agree or disagree with each statement. Please use the following scale:

  1. Strongly disagree
  2. Disagree
  3. Undecided
  4. Agree
  5. Strongly agree

The Dr. was open, honest, and thorough in answering you or your child's questions.

1 2 3 4 5
You feel you/your child are receiving adequate personal attention from the Dr. and Staff.

1 2 3 4 5
You/your child feel you have received fair value for the orthodontic fee.

1 2 3 4 5
You are happy with you/your child's treatment results.

1 2 3 4 5
You feel the Dr. and our staff really care.

1 2 3 4 5
You/your child are usually seen on time.

1 2 3 4 5
The physical environment of our office is up to your expectations.

1 2 3 4 5
Orthodontic emergencies are handled promptly.

1 2 3 4 5
You feel you would refer other patients to our practice.

1 2 3 4 5
What do you like best/least about our office?
Where do you think we need improvement?


Please add additional comments that would help us serve you and others.


Pope Orthodontics • Ted Pope, DDS, MSD
16 West Wenger Road • Englewood, OH 45322 • Phone: (937) 832-2087
6728 Loop Road, Suite 104 • Centerville, OH 45459 • Phone: (937) 438-1770

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