Valencia Dentist - Patient Survey

27450 Tourney Rd, Suite 250, Valencia, CA 91355


661-200-0687

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Patient Survey

Please take a moment to complete our survey. Your comments are welcome and completely confidential. Your input will help us improve our service. Thank you.

We appreciate you taking the time to complete our survey. Please feel free to comment on your visit as well. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.


Patient Name (optional):
E-mail Address (optional):
Date of your last visit (optional):
How was the treatment you received :
How comfortable were you during the treatment you received :
Was your treatment explained to you so that you have a clear understanding of your dental situation :
Were your financial options explained to you? :
How long did you wait before being seated in a room?
Would you refer your friends and family to us? :
Please comment below on how we could make your next visit better and more comfortable. Thank you.: Please enter code above in the field below.

Existing Patient Offer

Existing patients who refer a friend will receive their choice of a $50 credit on their account or a Salt Creek Gift Card. Existing patients will also have their name placed in drawing to win a $500 Southwest Airlines gift card.
(Drawing is May 1, 2012)

New Patient Offer

As our new patients you'll recieve The "H2Oral Irrigator," shower floss that provides you with a convienent and effective method of preventing the buildup of food particles and plaque in "problem" areas and helps maintain healthy teeth and gums with your initial exam.

Offer Expires 06/01/2012

Simply complete the form below to take advantage of either offer.

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Existing Patient Offer
Existing patients who refer a friend will receive their choice of a $50 credit on their account or a Salt Creek Gift Card. Existing patients will also have their name placed in drawing to win a $500 Southwest Airlines gift card. 
(Drawing is May 1, 2012)
New Patient Offer
As our new patients you'll recieve The "H2Oral Irrigator," shower floss that provides you with a convienent and effective method of preventing the buildup of food particles and plaque in "problem" areas and helps maintain healthy teeth and gums with your initial exam.
Offer Expires 06/01/2012
Simply complete the form below to take advantage of either offer.
</div>

Please enter code above in the field below.

Valencia Dentist · Drs. Kelly and Allen Smudde Dental · 27450 Tourney Road, Suite 250 · Valencia, CA · 91355