Patient Comment Card

Dr. Jason Bortolussi is an aesthetic dentist committed to

creating beautiful smiles

We ask that you complete the patient registration, medical and dental history forms, before your visit.

Fill out the online Patient Comment Card and submit your comments.

Print, fill out and bring into Dr.Bortolussi’s Office on your visit.

All Information submitted will go directly to the office management of Dr.Bortolussi and will remain confident & private.

1.Your overall experience in our Office: *

2. Flexibility in arranging appointments: *

3. Handling of your phone calls and scheduling your treatment: *

4. Explanation of treatment procedures: *

5. Our respect of your time: *

6. Courteousness and concern of receptionists: *

7. Courteousness and concern of chairside assistants: *

8. Courteousness and concern of the doctor: *

9. Professionalism and gentleness of chairside assistants: *

10. Professionalism and gentleness of doctor : *

11. The quality of the services we provide : *

12. The value of the services we provide : *

13. Would you recommend our office?: *

Yes

14. We would appreciate any comments you have about your experience in our office:

If you wrote a comment, would you be willing to let us use your first name and comments as a testimonial for our office information?:

Yes

Name (Optional):

Referring Doctor Name (Optional):

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