Online Referring Dentist Preference Survey

Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: btrepp@hotmail.com.

In our orthodontic practice, we recognize that to truly benefit your patient, orthodontic treatment must be a part of an ongoing dental care program. This can only be achieved by working in concert with the referring dentists in our area. Even if you are not now actively referring patients to Dr. Trepp, your feedback can help us do a better job. We would appreciate your taking time to give us your feelings about how you prefer your orthodontic patients to be treated.

Dentist Name:

Dentist Email Address:

Dental Office Internet Address:

Do you prefer initial panoramic radiographs be taken by

Our office
Your office

How often do you like to see your patients for cavity checkups and cleanings during orthodontic treatment?

Three Months
Six Months
Twelve Months
Other

How do you like initial consultation, treatment progress and post treatment reports from our office?

Brief description
In depth description
By US mail
By E-mail
By telephone
Multiple items may be chosen.

When is it most convenient to receive telephone calls from our office?

AM
Lunch
PM
After hours
No special time

After we have presented their orthodontic treatment plan, your patients

Understand their treatment
Often seek your clarification

How do you prefer to have referrals to other specialists be made

By our office
By your office
Always contact you first

How much orthodontic treatment do you provide in your office?

None
Some
Most
All

Do you have strong feelings about whether your patients are best treated with non-extraction or extraction orthodontics?

Yes
No

If yes, please elaborate on which technique that your prefer and why:

Preference:

What orthodontic problems do you feel merit primary or mixed dentition treatment?

Early Treatment Problems:

What problems do you feel should await treatment in the late mixed dentition or permanent dentition?

Late Treatment Problems:

Are you happy with the treatment timing that your patients have received at our office?

Yes
No

What technique or service should our office be offering that we are not?

Needed Service Offerings:

Why do you think your patients choose our office over others in our area?

Personal attention
Evening office hours
Fee level
Location
Patients seen on time
Multiple items may be chosen.

How do you believe our office's orthodontic fees are positioned in the local market place?

Low
Reasonable
High

Do you have any comments or suggestions for developing a better working relationship between our offices?

Suggestions:

Tell us about a new technique that your office is offering your patients that you and your assistants find exciting?

New Techniques:

To enhance communications, please list the names of keey employees in your office:

Key Employee Names Positions:

Do you wish to receive an E-mail confirmation when we receive this survey?

Yes
No

Thank you for sending us your candid answers to our survey. Our office will be using the information that you supplied to improve our services to your patients in our practice and new patients that you refer to our practice in the future. We appreciate your time and effort! Dr. Trepp's Orthodontic Team