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                                                        DR. DAN PETERSON

                                                                      1415 SAGE STREET ~ GERING, NEBRASKA 69341 
      Call: 308-436-3491           

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     We care about the level of service we offer to you.  We would be grateful if you would fill out this survey to let us know what you like about our practice as a patient of Family Gentle Dental Care and to also let us know in what areas we need to take action to correct and improve our services to you.

     The results of this survey is private and will be kept confidential and used only to improve our level of care to you. We respect your privacy

Working hard to bring you better patient care

We care about you and want to know how we can better serve you!

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Please check one of the boxes if you like us to personally respond back to you through your e-mail address about the actions we took regarding your feedback?      Yes  No

Date of visit:  

1.  Was our staff caring and friendly? Yes: No: 


2.  Were there any questions or concerns that were not taken care of in a timely 

    manner? Yes: No:


3.  Did cleanliness and infection control of our practice meet your expectations?

     Exceeded expectations: Meet expectations: Below expectations:

4.  Comments on the atmosphere and decor of our office:


5.  Where your fears about dental procedures listened to, discussed and cared for?

     Yes: No:  


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6.  Was your treatment performed on time?

     Exceeded expectation: Meet expectation: Below expectation:

7.Are financial matters handled in a timely and well addressed manner?

      Yes: No:  


8.  Where there any problems during your visit?  If so, please describe them so we may address them at our daily morning meetings:

9.  Would you recommend our practice to your family members and friends?

     Yes: No:  


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10.  Was there a staff member that was particularly caring and helpful that you would like to thank or a staff member that needs to address any issues that were not dealt with to your satisfaction at your visit?


I would like more information about:       


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          If you have any questions please e-mail me at:
                                                                                 308-436-3491 Office number

PLEASE NOTE: The information contained herein is intended for educational purposes only.  It is not intended and should not be construed as the delivery of dental/medical care and is not a substitute for personal hands on dental/medical attention, diagnosis or treatment.  Persons requiring diagnosis, treatment, or with specific questions are urged to contact your family dental/health care provider for appropriate care.
This site is privately and personally sponsored, funded and supported by Dr. Peterson.  We have no outside funding.
Confidentiality of data including your identity, is respected  by this Web site. We undertake to honor or exceed the legal requirements of medical/health information privacy that apply in Nebraska.

Copyright 1998-2008 Family Gentle Dental Care, all rights reserved.