Creating Confidence
Patient Survey

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* 1. After completing treatment at Queensway, has your smile made you feel more confident?

Yes

No

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* 2. If you have answered yes, can you tell us how?

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* 3. Using any number from 0 to 10, where 0 is not at all and 10 is extremely, what number would you use to rate your confidence BEFORE dental treatment at Queensway?

	0 Not at all confident	1	2	3	4	5	6	7	8	9	10 Extremely confident
.	. 0 Not at all confident	. 1	. 2	. 3	. 4	. 5	. 6	. 7	. 8	. 9	. 10 Extremely confident

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* 4. Using any number from 0 to 10, where 0 is not at all and 10 is extremely, what number would you use to rate your confidence AFTER dental treatment at Queensway?

	0 Not at all confident	1	2	3	4	5	6	7	8	9	10 Extremely confident
.	. 0 Not at all confident	. 1	. 2	. 3	. 4	. 5	. 6	. 7	. 8	. 9	. 10 Extremely confident

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* 5. If you would like to be entered into our prize draw to win a £20 voucher, let us know your email address.

Email Address