After Examination Questionnaire

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

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

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

1 2 3 4 5
You/your child received personal attention.

1 2 3 4 5
Fee arrangements were flexible and easy to complete.

1 2 3 4 5
The physical environment of the office met your expectations.

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

1 2 3 4 5
The need for orthodontic care is understood by you/your child.

1 2 3 4 5
You/your child understands the treatment time.

1 2 3 4 5
The Dr. and Staff explained all procedures to you/your child before they were done.

1 2 3 4 5
You would refer your friends who need orthodontic care to Pope Orthodontics.

1 2 3 4 5
Our office location was convenient to find.

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


How did you hear about our office?
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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