Wickenburg Dentist - Edward Kirk DDS

Doctor Kirk

Rate your visit

It's our goal to provide you with the best possible dental care. To that end, we'd love to hear what you thought about your recent visit to our office. If you'd like to share your thoughts with us, you can do so using the form below. Just fill in the empty fields and click "submit".

1: If you would like a response, please complete the following information

First Name:
Last Name:
E-Mail Address: (required)
City:
Last Visit:

2: General Comments

What did you enjoy about your visit?

What would you like to change about your visit?

Did we address your primary concerns? Please explain

Using a scale of 1-5 (1=poor, 5=excellent) please click on the circle value that best rates the following aspects of your last dental visit.

Office

Parking

1	2	3	4	5

Decor

1	2	3	4	5

Staff

Staff Friendliness

1	2	3	4	5

Staff Intelligence

1	2	3	4	5

Cared About Your Problem

1	2	3	4	5

Promptness

1	2	3	4	5

Personal Appearance

1	2	3	4	5

Doctor Kirk

Friendliness

1	2	3	4	5

Intelligence

1	2	3	4	5

Cared About Your Problem

1	2	3	4	5

Promptness

1	2	3	4	5

Personal Appearance

1	2	3	4	5

Dental Assistant

Friendliness

1	2	3	4	5

Intelligence

1	2	3	4	5

Cared About Your Problem

1	2	3	4	5

Promptness

1	2	3	4	5

Personal Appearance

1	2	3	4	5

Dental Hygienist

Friendliness

1	2	3	4	5

Intelligence

1	2	3	4	5

Cared About Your Problem

1	2	3	4	5

Promptness

1	2	3	4	5

Personal Appearance

1	2	3	4	5

Your Experience

Understood Your Treatment

1	2	3	4	5

Comfortable during treatment

1	2	3	4	5

Your Bill

Knew cost before treatment

1	2	3	4	5

Payment terms understood

1	2	3	4	5

Website

Ease of navigation

1	2	3	4	5

Appearance

1	2	3	4	5

Helped me making make Dr. Kirk my choice for treatment

1	2	3	4	5

Other

How did you hear about Dr. Kirk?
(Check All that apply)

Friend	Newspaper	Chamber	Website	Other

Can we use your comments and name on our website?

Additional Comments

Edward F. Kirk, D.D.S., P.C.
1175 W. Wickenburg Way #1
Wickenburg, Arizona 85390
Phone: 928-684-7817