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My Family Dental Care

1. Is this your first visit in our office?
Yes No. I am a returning patient
2. How did you hear about us?
Family or Friends Yellow Pages/ Phone Directory
Outdoor Advertising (Posters, Billboards) From my Insurance
Newspaper or Magazine Advertisement Web search / Internet
Other
If Other, Please specify
3. How far did you travel to see our dentist?
Less than 5 miles 6%u201410 miles More than 10 miles
4. Do you carry Dental Insurance?
Yes No. Go to question 7
If Yes, Please specify which one
5. How did you obtain the Insurance?
Through Employer I qualified for MEDICAID / MEDICARE I purchased on my own
Other
If Other, Please specify
6. Are you satisfied with your current Insurance Plan?
Very satisfied; I would not change anything. Not satisfied; I am looking to change my plan Somewhat satisfied
If not Satisfied, Please specify all you are not pleased with (check all that apply)
The copayment The pre-existing condition clause
The yearly maximum limit Preauthorization required
Other
If Other, Please Specify
7. Your Gender:
Male Female
8. Age group
- 20 21-30 31-50
51-65 65 -
9. Number of members in your family
Of which, number of Children are
10. Family Income per year
Less than $50,000 $50,000-$75,000 $75,001-$100,000
Over $100,000
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