1. How often do you go for a dental checkup?

Select one answer

Every 6 months
Once a year
Every 2 to 3 years
Only when something hurts

2. What makes you put off a dental checkup?

Select one or more answers

The cost
Fear or discomfort
I cannot find the time
Nothing hurts, so it feels unnecessary
I forget when it is due
I cannot get an appointment that suits me
Nothing, I go regularly

3. Have you had the treatment we recommended?

Select one answer

Yes, all of it
Some of it, not all
Not yet, the cost put me off
Not yet, I was nervous about it
Not yet, I could not find the time
I have not been recommended any treatment

4. Does anyone at home go to a different dentist?

Select one or more answers

No, we all go to the same dentist
Yes, my partner
Yes, my children
Yes, someone else in the household
I live alone

5. How should we remind you about a checkup?

Select one answer

Text message
E-mail
Phone call
I would rather book it myself

6. How did you first hear about us?

Select one answer

Someone recommended it
Another dentist or doctor referred me
I found it online
I passed by it
From my insurance or employer
I cannot remember

7. How likely are you to recommend [practice name]?

Not at all likely

Extremely likely

8. What would make your next visit easier?

500

Dental Patient Checkup Habits

Who it's for

Dental practices with a patient list to look after. Send it once a year to everyone, including the people you have not seen in a while.

Who answers

Your patients, on a phone, in two minutes. No medical questions.

Use template

What you'll see

Why people put off a check-up: fear, money, time, or nobody reminded them
Who was offered treatment and never went through with it
Which reminder people actually want: text, email, phone, or a card in the post
Whether the rest of the household has a dentist, which is where new patients come from

How to get good answers

Send it to the whole list, not just to people who came in recently. The ones who stay away are the point of the exercise.
Ask about the reminder and then change how you remind people. If you do nothing with that answer, do not ask the question.
Ask nothing about anyone's teeth or treatment. Keep it to habits and to how the practice runs.
The gap between treatment offered and treatment done is money already on your table. Read that one question first.

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Do you put off the dentist?

1. How often do you go for a dental checkup?

2. What makes you put off a dental checkup?

3. Have you had the treatment we recommended?

4. Does anyone at home go to a different dentist?

5. How should we remind you about a checkup?

6. How did you first hear about us?

7. How likely are you to recommend [practice name]?

8. What would make your next visit easier?