Evaluation Form

1100 Richmond Avenue, Unit B
Brandon R7A 1m6
Manitoba
Canada
Tel (204) 727-6453
Fax (204) 571-1560
Email Us

We want to hear from you!

As part of our effort to provide the best quality orthodontic care, we are asking you to please take a few minutes to give us your thoughts.

Please choose the answer that best describes your feelings and experiences.

User Information

Name : Email Address :

Telephone Courtesy

Poor
Good
Excellent

Seen on Time

Yes
No

Scheduling Appointments

Poor
Good
Excellent

Friendliness

Poor
Good
Excellent

Care by Dr. Bales

Poor
Good
Excellent

Care by Staff

Poor
Good
Excellent

Quality of Treatment

Poor
Good
Excellent

Was there anyone in our office that made your experience special or difficult?

Yes
No

Why?

What else could we do to improve a patient's experience in our office?

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