Cornell McCullom III, D.D.S., M.D.
Yetta G. McCullom, D.D.S., M.S.
Robin L. Ferguson, D.D.S., P.C.

Patient Survey

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

E-mail address

How would you rate your overall visit?
Excellent Very Good Average Not so good

When your appointment was over did you have a good understanding of your dental situation?
Yes Not really I wish I knew more about my situation

Were your financial options explained to you?
Yes No I already understand my financial options

Did you have to wait over 15 minutes past your appointment time to be seated? If so how long?
No 15 to 30 minutes 30 to 45 minutes Over 45 minutes

Did the staff greet you properly?
Yes Not really I don't recall

Would you refer your friends and family to us?
Yes No I'm not sure

Please comment on how we could make your visit better, new services you would like to see, or other ways we can make you feel more comfortable.

820 East 87th Street Suite 201
Chicago IL 60619
Phone: 773.488.3738
Fax: 773.874.6575

Home | About Us | Dental Services | Smile Gallery | FAQs | Links | Dental Articles | Newsletter
Patient Survey | New Patient Forms | Ask The Doctors | Make An Appointment | In the Media | Contact Us
©2004 Dr. Cornell McCullom ~ Site designed and maintained by TNT Dental