Bellaire, TX (Texas) Orthodontist Partners David M. Wadler and Melissa Wadler Bloome

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We have enjoyed working with you and would appreciate your help in making our relationship together as fulfilling as possible. We are always trying to improve our practice and would like to ask you to please take a moment to answer the following questions so that we may serve you even better!

1. Are you pleased with the manner in which we treated you personally?	Yes	No
Why/why not?
2. If you have children in treatment, are they pleased with the way they are being treated?	Yes	No
Why/why not?
3. Recognizing that quality orthodontics cannot be kept to a precise schedule, are you generally pleased with our scheduling system?	Yes	No
Why/why not?
4. Do you find our staff to be willing and eager to help?	Yes	No
5. Has everything been clearly explained to your satisfaction?	Yes	No
6. Do you know what to do if a problem arises with the braces?	Yes	No
7. Please note any areas you feel we could improve:
8. Please note the things about our practice you especially like:
9. Our practice is built on the recommendations of our happy, satisfied patients and parents. Can we count on you to refer your friends to us?	Yes	No
Thank you for letting us know how we are doing! If you do not type your name in the space below, the results of this survey will be entirely anonymous.

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Date:

5001 Bissonnet Street, Suite 105 | Bellaire, TX 77401 | (713) 667-6000