To Our Patients

To assist us in our effort to provide you with the best possible dental care, please take the time to answer these questions. They are designed to bring areas of concern to our attention, as well as let us know what we are doing right.

All of the information that you provide will be held strictly confidential and goes directly to our General Manager.

Your Dentist

Which dentist did you visit? (Required)
Dr. Hakimi Dr. Eben

What was the date of your visit?

Do you usually wait more than 15 minutes for a scheduled appointment?
Always Sometimes Never

During your appointment, does your dentist appear familiar with your chart and dental history?
Always Sometimes Never

Does your dentist explain why treatment is recommended?
Always Sometimes Never

Does your dentist answer your questions and explain things clearly?
Always Sometimes Never

Does your dentist spend enough time with you?
Always Sometimes Never

Are you treated courteously and respectfully by your dentist and staff?
Always Sometimes Never

Do you see your dentist as being approachable, sympathetic, and understanding?
Always Sometimes Never

Does the dentist make sure you are comfortable during treatment?
Always Sometimes Never

Your Hygienist

Which hygienist worked with you during your visit? (Required)
Karla Sparks Kim Wilson April Larsen

What was the date of your visit?

Do you usually wait more than 15 minutes for a scheduled appointment?
Always Sometimes Never

During your appointment, does your Dental Hygienist appear familiar with your chart and dental history?
Always Sometimes Never

Does your Dental Hygienist explain why treatment is recommended?
Always Sometimes Never

Does your Dental Hygienist answer your questions and explain things clearly?
Always Sometimes Never

Does your Dental Hygienist spend enough time with you?
Always Sometimes Never

Does the Dental Hygienist make sure you are comfortable during treatment?
Always Sometimes Never

The Office

Is adequate parking available?
Always Sometimes Never

Is there a variety of appropriate reading material available in the reception area?
Always Sometimes Never

Is the telephone answered promptly?
Always Sometimes Never

Are you able to get an appointment in what you consider to be a reasonable amount of time?
Always Sometimes Never

Does the office staff assist you in filling out insurance and other forms?
Always Sometimes Never

Does the office staff maintain your privacy when discussing financial arrangement and other personal matters with you?
Always Sometimes Never

Does the office staff notify you if appointments are running behind schedule?
Always Sometimes Never

Would you refer your friends and family to Westlake Smile Design?
Yes No

Have you referred any patients to Westlake Smile Design?
Yes No





Full Name (optional)


Email Address (optional)


Phone Number (optional)
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We would greatly appreciate any additional feedback: