This printable dental patient satisfaction survey helps dental practices collect honest feedback from every patient across 25 questions, including those who never open an email or online portal. The form prints on three pages and takes about five minutes to complete.
What this survey measures
The survey follows the patient's visit from start to finish: the reason for the visit, who they saw, how they booked, and how long they waited. A rating grid covers the reception team, opening hours, the waiting area, the hygienist and dentist, comfort and pain management, cleanliness, value for money, and payment. The treatment section asks whether the dentist listened and explained options clearly, how well costs were explained, and how anxious the patient feels about dental visits. A short oral health section records brushing habits, visit frequency, and current problems such as sensitive teeth or bleeding gums, and an information and aftercare section checks home care advice, a written treatment plan, and who to contact after treatment. An overall rating, a likelihood-to-recommend question, and the intention to return give you simple scores to track over time, and two comment boxes capture what went well and what could be better.
How to use it on paper
Hand the survey to patients at checkout or leave copies in the waiting room with a drop box at reception. Patients fill the checkboxes with a blue or black pen. Collect the completed forms and scan them in batches: PaperSurvey reads the checkbox answers with optical mark recognition and converts the handwritten comments to text automatically, so results appear in your dashboard without any manual data entry.
Customize this template
Add your practice logo, reword the grid rows to match your services, or add questions about specific treatments and providers. The paper layout reflows automatically as you edit, and every copy you print stays scannable.
Preview the PDF above, or use this template to start collecting patient feedback today.