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Pellegrini Orthodontics Exit Survey

Please complete the form below

Your feedback is extremely important to us! Please take the time to tell us about your overall experience with our office. Thank you for your thoughts!

Your Name

First Name

Last Name

Patient Name (if not the same as above)

First Name

Last Name

Please tell us what you think about Dr. Pellegrini

Please tell us what you think about the Pellegrini Orthodontics staff

Why did you select our office for your orthodontic treatment?

Are you likely to recommend our office to friends or family who need orthodontic treatment? Why or why not?

Additional comments or feedback

How satisfied are you with your overall experience

What do you like best about our office?

Please select all that apply

The doctor

The staff

Office enviornment

Movies in the clinic

Office contests and events

Greenies

Reception area

Location

Website

Other favorite thing about our office:

Are you willing to have some or all of your comments shared on our website?

Do you give consent to share a celebration photo of your debond day on our social media?

We love to show off our patients excellent progress! Would you be willing to have you or your child featured in our 'Before & After' gallery?

Have you changed dentists during your orthodontic treatment? If so, who is your current dentist?