Charles R. Payerle, DDS, MD
Oral & Maxillofacial Surgery
12001 South Freeway, Suite 207, Burleson, TX 76028
P. 817-568-6811     F. 817-568-6813

Patient Survey

Name of Physician your visit was with?

Would you like us to contact you regarding your visit?

If yes, please give us your name     and phone number  


Response definition:   P = poor   F = fair   G = good   VG = very good   E = excellent

1. Ease of scheduling appointments:

2. Friendliness of appointment scheduler:

3. Convenience of our clinic hours:

4. Availability of parking:

5. Timeliness of registration process:

6. Courtesy shown by reception staff:

7. Satisfaction with length of time between registration and exam:

8. Explanation of any prolonged wait, if applicable:

9. Friendliness and concern of your care provider (assistant, dr):

10. Opportunity to discuss your concerns with the doctor:

11. Was your medical condition and treatment explained thoroughly?

12. Were you able to understand explanation and instructions?

13. Were you able to understand the financial information?