Northeast Portland Dentist, Dr. Jon M. Daby DDS, proudly serves NE Portland, Portland Metro, Rose City Park, Roseway, Cully, Sumner, and Hollywood, Oregon providing the finest in cosmetic, restorative, and sedation dentistry.
	6600 NE Sandy Blvd., Portland, OR 97123

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Patient Survey

Please take a moment to complete our survey. Your comments are welcome and completely confidential. Your input will help us improve our service. Thank you.

We appreciate you taking the time to complete our survey. Please feel free to comment on your visit as well. Any comments you choose to make are kept strictly confidential and can only help us become better in the future.


Patient Name :
E-mail Address :
Date of your last visit:
How was the treatment you received :
How comfortable were you during the treatment you received :
Was your treatment explained to you so that you have a clear understanding of your dental situation :
Were your financial options explained to you? :
How long did you wait before being seated in a room?
Would you refer your friends and family to us? :
Please comment below on how we could make your next visit better and more comfortable. Thank you.: Please enter code above in the field below.

New Patient Offer

Free whitening with purchase of new patient exam and full set of
X-rays (a $400 value).

$100 off any restorative or cosmetic procedure with
purchase of new patient exam
and full set of X-rays.

To take advantage of one of the amazing offers above, simply
complete the form below before
the deadline.

Offers Expire
02/09/2012

In the message box, indicate which offer you are choosing:

Please enter code above in the field below.

Northeast Portland Oregon Dental Care Dentist