Patient Deactivation Survey

We are truly saddened to see you leave our practice, as your trust means so much to us. Your feedback is incredibly valuable in helping us improve and better meet our patients’ expectations.

Kindly take a moment to complete this short survey, as we genuinely care to hear from you and would like to understand the reasons that made you take your decision.

Thank you for allowing us to be part of your dental journey.

Full name

1- What was your overall satisfaction with our dental office before deciding to leave?

2- How would you rate the quality of care and treatment you received from our clinical team?

How satisfied were you with our customer service, including scheduling, communication, and billing?

Did you feel valued and listened to as a patient during your time with us?

How likely would you have been to stay with our practice if improvements were made in the areas that led to your decision to leave?

Before deciding to leave, did you escalate your concerns to management for resolution?
YesNo

In which office were you treated?

Optional: Please share any additional comments about your experience. Your honest feedback is greatly appreciated.

Thank you for your time—we truly value your input!

You Make Me Smile Dental Centre is a full-service dental centre, and we are proud to be serving Belleville & Trenton. Quinte West and beyond! We have two convenient locations, both offer a wide range of dental health services to give you the smile you deserve!

Patient Deactivation Survey