Dental Visit Feedback Form
This dental visit feedback form helps dental practices collect actionable patient feedback. It covers the complete patient journey from check-in to treatment to checkout, with specific focus on pain level management, staff professionalism, and treatment explanation. The form includes anxiety-sensitive questions and pain scale measurements to help practices improve patient comfort and care quality.
Try the Form
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export function dentalVisitFeedback(form: FormTs) {
// Dental Visit Feedback - Patient satisfaction survey for dental practices
// Demonstrates: Slider (pain scale), EmojiRating, StarRating, MatrixQuestion, RatingScale, ThumbRating, dynamic styling
// ============================================
// HEADER
// ============================================
form.addRow(row => {
row.addTextPanel('header', {
label: 'Dental Visit Feedback',
computedValue: () => 'Your feedback helps us provide better care',
customStyles: {
backgroundColor: '#0ea5e9',
color: 'white',
padding: '24px',
borderRadius: '12px',
textAlign: 'center'
}
});
});
// ============================================
// SECTION 1: Visit Information
// ============================================
const visitInfo = form.addSubform('visitInfo', {
title: 'Visit Details',
customStyles: { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' }
});
visitInfo.addRow(row => {
row.addDropdown('visitType', {
label: 'Type of Visit',
options: [
{ id: 'cleaning', name: 'Cleaning & Checkup' },
{ id: 'filling', name: 'Filling' },
{ id: 'extraction', name: 'Extraction' },
{ id: 'root-canal', name: 'Root Canal' },
{ id: 'crown', name: 'Crown/Bridge' },
{ id: 'whitening', name: 'Whitening' },
{ id: 'orthodontic', name: 'Orthodontic Visit' },
{ id: 'emergency', name: 'Emergency Visit' },
{ id: 'consultation', name: 'Consultation Only' },
{ id: 'other', name: 'Other' }
],
placeholder: 'Select visit type',
isRequired: true
}, '1fr');
row.addDropdown('seenBy', {
label: 'Primary Provider',
options: [
{ id: 'dentist', name: 'Dentist' },
{ id: 'hygienist', name: 'Dental Hygienist' },
{ id: 'orthodontist', name: 'Orthodontist' },
{ id: 'oral-surgeon', name: 'Oral Surgeon' },
{ id: 'multiple', name: 'Multiple Providers' }
],
placeholder: 'Who did you see?'
}, '1fr');
});
visitInfo.addRow(row => {
row.addRadioButton('isFirstVisit', {
label: 'Is this your first visit to our practice?',
options: [
{ id: 'yes', name: 'Yes, first visit' },
{ id: 'no', name: 'No, returning patient' }
],
orientation: 'horizontal'
});
});
// ============================================
// SECTION 2: Pre-Visit Anxiety
// ============================================
const anxietySection = form.addSubform('anxietySection', {
title: 'Dental Anxiety',
customStyles: { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' }
});
anxietySection.addRow(row => {
row.addEmojiRating('anxietyBefore', {
label: 'How anxious were you BEFORE your visit?',
preset: 'custom',
emojis: [
{ id: 'none', emoji: '😌', label: 'Calm' },
{ id: 'mild', emoji: '😐', label: 'Slightly nervous' },
{ id: 'moderate', emoji: '😟', label: 'Anxious' },
{ id: 'severe', emoji: '😰', label: 'Very anxious' },
{ id: 'extreme', emoji: '😱', label: 'Terrified' }
],
size: 'lg',
showLabels: true,
alignment: 'center'
});
});
anxietySection.addRow(row => {
row.addEmojiRating('anxietyAfter', {
label: 'How did you feel AFTER your visit?',
preset: 'custom',
emojis: [
{ id: 'relieved', emoji: '😊', label: 'Relieved' },
{ id: 'calm', emoji: '😌', label: 'Calm' },
{ id: 'neutral', emoji: '😐', label: 'Neutral' },
{ id: 'uncomfortable', emoji: '😕', label: 'Uncomfortable' },
{ id: 'distressed', emoji: '😫', label: 'Distressed' }
],
size: 'lg',
showLabels: true,
alignment: 'center'
});
});
// ============================================
// SECTION 3: Pain Management
// ============================================
const painSection = form.addSubform('painSection', {
title: 'Pain & Comfort',
isVisible: () => {
const visitType = visitInfo.dropdown('visitType')?.value();
return visitType !== 'consultation' && visitType !== null;
},
customStyles: () => {
const pain = painSection.slider('painLevel')?.value();
if (pain !== null && pain !== undefined) {
if (pain <= 2) return { backgroundColor: '#d1fae5', padding: '16px', borderRadius: '8px' };
if (pain <= 5) return { backgroundColor: '#fef3c7', padding: '16px', borderRadius: '8px' };
return { backgroundColor: '#fee2e2', padding: '16px', borderRadius: '8px' };
}
return { padding: '16px', borderRadius: '8px', border: '1px dashed #cbd5e1' };
}
});
painSection.addRow(row => {
row.addSlider('painLevel', {
label: 'Pain level during procedure (0 = no pain, 10 = worst pain)',
min: 0,
max: 10,
step: 1,
showValue: true,
defaultValue: 0
});
});
painSection.addRow(row => {
row.addTextPanel('painDescription', {
computedValue: () => {
const pain = painSection.slider('painLevel')?.value();
if (pain === null || pain === undefined) return 'Move the slider to rate your pain level';
if (pain === 0) return '😊 No pain - perfect!';
if (pain <= 2) return '😌 Minimal discomfort';
if (pain <= 4) return '😐 Mild pain - manageable';
if (pain <= 6) return '😕 Moderate pain';
if (pain <= 8) return '😣 Significant pain';
return '😫 Severe pain - we need to address this';
},
customStyles: () => {
const pain = painSection.slider('painLevel')?.value();
const baseStyles = {
textAlign: 'center',
padding: '12px 16px',
borderRadius: '8px',
fontWeight: 'bold'
};
if (pain !== null && pain !== undefined) {
if (pain <= 2) return { ...baseStyles, backgroundColor: '#10b981', color: 'white' };
if (pain <= 5) return { ...baseStyles, backgroundColor: '#f59e0b', color: 'white' };
return { ...baseStyles, backgroundColor: '#ef4444', color: 'white' };
}
return { ...baseStyles, backgroundColor: '#e2e8f0', color: '#475569' };
}
});
});
painSection.addRow(row => {
row.addThumbRating('anesthesiaEffective', {
label: 'If anesthesia was used, was it effective?',
showLabels: true,
upLabel: 'Yes, worked well',
downLabel: 'No, felt pain',
alignment: 'center',
size: 'lg'
});
});
// ============================================
// SECTION 4: Staff & Care Quality
// ============================================
const staffSection = form.addSubform('staffSection', {
title: 'Staff & Care Quality',
isVisible: () => visitInfo.dropdown('visitType')?.value() !== null,
customStyles: { padding: '16px', borderRadius: '8px', border: '1px solid #e2e8f0' }
});
staffSection.addRow(row => {
row.addMatrixQuestion('staffRatings', {
label: 'Rate our team:',
rows: [
{ id: 'reception', label: 'Front Desk / Reception', description: 'Check-in process and friendliness', isRequired: true },
{ id: 'hygienist', label: 'Dental Hygienist', description: 'Care and technique', isRequired: false },
{ id: 'dentist', label: 'Dentist / Doctor', description: 'Expertise and bedside manner', isRequired: true },
{ id: 'assistant', label: 'Dental Assistant', description: 'Helpfulness during procedure', isRequired: false }
],
columns: [
{ id: 'na', label: 'N/A' },
{ id: '1', label: 'Poor' },
{ id: '2', label: 'Fair' },
{ id: '3', label: 'Good' },
{ id: '4', label: 'Very Good' },
{ id: '5', label: 'Excellent' }
],
striped: true,
fullWidth: true
});
});
staffSection.addRow(row => {
row.addStarRating('explanationQuality', {
label: 'How well did the dentist explain your treatment?',
maxStars: 5,
size: 'lg',
alignment: 'center'
});
});
staffSection.addRow(row => {
row.addRatingScale('listenedConcerns', {
preset: 'likert-5',
label: 'The dental team listened to my concerns and questions',
lowLabel: 'Strongly Disagree',
highLabel: 'Strongly Agree',
alignment: 'center'
});
});
// ============================================
// SECTION 5: Wait Time & Scheduling
// ============================================
const waitSection = form.addSubform('waitSection', {
title: 'Wait Time & Scheduling',
isVisible: () => visitInfo.dropdown('visitType')?.value() !== null
});
waitSection.addRow(row => {
row.addDropdown('waitTime', {
label: 'How long did you wait past your appointment time?',
options: [
{ id: 'on-time', name: 'Seen on time or early' },
{ id: '5-10', name: '5-10 minutes' },
{ id: '10-20', name: '10-20 minutes' },
{ id: '20-30', name: '20-30 minutes' },
{ id: '30+', name: 'More than 30 minutes' }
],
placeholder: 'Select wait time'
}, '1fr');
row.addStarRating('waitSatisfaction', {
label: 'Satisfaction with wait',
maxStars: 5,
size: 'lg',
alignment: 'left'
}, '1fr');
});
waitSection.addRow(row => {
row.addRatingScale('easyScheduling', {
preset: 'likert-5',
label: 'It was easy to schedule this appointment',
lowLabel: 'Strongly Disagree',
highLabel: 'Strongly Agree',
alignment: 'center'
});
});
// ============================================
// SECTION 6: Facility
// ============================================
const facilitySection = form.addSubform('facilitySection', {
title: 'Facility & Environment',
isVisible: () => visitInfo.dropdown('visitType')?.value() !== null
});
facilitySection.addRow(row => {
row.addStarRating('cleanliness', {
label: 'Office Cleanliness',
maxStars: 5,
size: 'lg',
alignment: 'left'
}, '1fr');
row.addStarRating('comfort', {
label: 'Comfort of Treatment Area',
maxStars: 5,
size: 'lg',
alignment: 'left'
}, '1fr');
});
facilitySection.addRow(row => {
row.addCheckboxList('facilityHighlights', {
label: 'What did you appreciate about our facility?',
options: [
{ id: 'clean', name: 'Very clean and hygienic' },
{ id: 'modern', name: 'Modern equipment' },
{ id: 'comfortable-chairs', name: 'Comfortable chairs' },
{ id: 'tv', name: 'TV/Entertainment during treatment' },
{ id: 'music', name: 'Relaxing music' },
{ id: 'waiting-area', name: 'Nice waiting area' },
{ id: 'parking', name: 'Easy parking' },
{ id: 'kids-friendly', name: 'Kid-friendly environment' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 7: Overall Satisfaction
// ============================================
const overallSection = form.addSubform('overallSection', {
title: 'Overall Experience',
isVisible: () => visitInfo.dropdown('visitType')?.value() !== null,
customStyles: () => {
const rating = overallSection.starRating('overallRating')?.value();
if (rating && rating >= 5) return { backgroundColor: '#d1fae5', padding: '16px', borderRadius: '8px' };
if (rating && rating >= 3) return { backgroundColor: '#fef3c7', padding: '16px', borderRadius: '8px' };
if (rating && rating >= 1) return { backgroundColor: '#fee2e2', padding: '16px', borderRadius: '8px' };
return { padding: '16px', borderRadius: '8px', border: '1px dashed #cbd5e1' };
}
});
overallSection.addRow(row => {
row.addStarRating('overallRating', {
label: 'Overall Experience Rating',
maxStars: 5,
size: 'xl',
alignment: 'center',
showConfettiOnMax: true
});
});
overallSection.addRow(row => {
row.addThumbRating('wouldRecommend', {
label: 'Would you recommend our practice to friends and family?',
showLabels: true,
upLabel: 'Yes!',
downLabel: 'No',
alignment: 'center',
size: 'lg'
});
});
overallSection.addRow(row => {
row.addThumbRating('willReturn', {
label: 'Will you return for future dental care?',
showLabels: true,
upLabel: 'Definitely',
downLabel: 'Probably not',
alignment: 'center',
size: 'lg'
});
});
overallSection.addSpacer();
overallSection.addRow(row => {
row.addTextarea('comments', {
label: 'Additional comments or suggestions',
placeholder: 'Share anything else about your visit...',
rows: 3,
autoExpand: true
});
});
// ============================================
// SECTION 8: Summary
// ============================================
const summarySection = form.addSubform('summarySection', {
title: 'Visit Feedback Summary',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null
});
summarySection.addRow(row => {
row.addTextPanel('summaryContent', {
computedValue: () => {
const visitType = visitInfo.dropdown('visitType')?.value();
const overall = overallSection.starRating('overallRating')?.value();
const pain = painSection.slider('painLevel')?.value();
const anxietyBefore = anxietySection.emojiRating('anxietyBefore')?.value();
const anxietyAfter = anxietySection.emojiRating('anxietyAfter')?.value();
const cleanliness = facilitySection.starRating('cleanliness')?.value();
const explanation = staffSection.starRating('explanationQuality')?.value();
const recommend = overallSection.thumbRating('wouldRecommend')?.value();
const willReturn = overallSection.thumbRating('willReturn')?.value();
if (!overall) return '';
const visitLabels: Record<string, string> = {
'cleaning': 'Cleaning & Checkup',
'filling': 'Filling',
'extraction': 'Extraction',
'root-canal': 'Root Canal',
'crown': 'Crown/Bridge',
'whitening': 'Whitening',
'orthodontic': 'Orthodontic Visit',
'emergency': 'Emergency Visit',
'consultation': 'Consultation',
'other': 'Other'
};
let summary = `DENTAL VISIT FEEDBACK\n`;
summary += `${'═'.repeat(25)}\n\n`;
if (visitType) {
summary += `Visit Type: ${visitLabels[visitType] || visitType}\n`;
}
summary += `Overall: ${'★'.repeat(overall)}${'☆'.repeat(5 - overall)} (${overall}/5)\n`;
if (pain !== null && pain !== undefined) {
const painEmoji = pain <= 2 ? '😊' : pain <= 5 ? '😐' : '😣';
summary += `Pain Level: ${painEmoji} ${pain}/10\n`;
}
if (anxietyBefore && anxietyAfter) {
const improved = ['relieved', 'calm'].includes(anxietyAfter);
summary += `Anxiety: ${improved ? '✅ Reduced' : '⚠️ Present'}\n`;
}
if (cleanliness) {
summary += `Cleanliness: ${cleanliness}/5\n`;
}
if (explanation) {
summary += `Explanation: ${explanation}/5\n`;
}
summary += `\n`;
if (recommend) {
summary += `${recommend === 'up' ? '👍 Would recommend' : '👎 Would not recommend'}\n`;
}
if (willReturn) {
summary += `${willReturn === 'up' ? '🔄 Will return' : '❌ May not return'}\n`;
}
return summary;
},
customStyles: () => {
const overall = overallSection.starRating('overallRating')?.value();
const baseStyles = {
padding: '16px',
borderRadius: '8px',
whiteSpace: 'pre-wrap',
fontFamily: 'monospace',
fontSize: '13px'
};
if (overall && overall >= 4) {
return { ...baseStyles, backgroundColor: '#d1fae5', borderLeft: '4px solid #10b981' };
} else if (overall && overall >= 3) {
return { ...baseStyles, backgroundColor: '#fef3c7', borderLeft: '4px solid #f59e0b' };
} else if (overall && overall >= 1) {
return { ...baseStyles, backgroundColor: '#fee2e2', borderLeft: '4px solid #ef4444' };
}
return { ...baseStyles, backgroundColor: '#f8fafc', borderLeft: '4px solid #0ea5e9' };
}
});
});
// ============================================
// FORM CONFIGURATION
// ============================================
form.configureSubmitButton({
label: 'Submit Feedback',
isVisible: () => overallSection.starRating('overallRating')?.value() !== null
});
form.configureCompletionScreen({
type: 'text',
title: 'Thank You for Your Feedback!',
message: 'Your input helps us provide better dental care. We appreciate you taking the time to share your experience with us.'
});
}
Frequently Asked Questions
How soon after a dental visit should I send the feedback form?
Send within 24-48 hours while the experience is fresh. For procedures involving recovery, consider a follow-up survey at the 1-week mark to capture post-treatment satisfaction.
How do I measure dental anxiety effectively?
This form uses validated emoji-based anxiety scales and asks about anxiety before vs. after treatment. This helps identify which aspects of your practice help reduce patient anxiety.
Should I ask about pain levels for routine cleanings?
Yes, even routine cleanings can cause discomfort for some patients. The pain scale section is conditional and allows patients to skip if not applicable. This data helps improve technique and identify sensitivity issues.
How can I use this feedback to improve my dental practice?
Focus on recurring themes: if multiple patients mention wait times, improve scheduling. If pain scores are high for specific procedures, review techniques or consider additional anesthesia options. Share positive feedback with staff for morale.
Is this form HIPAA compliant?
The form template itself doesn't collect PHI beyond general satisfaction feedback. For full HIPAA compliance, ensure your hosting platform is HIPAA-compliant and avoid asking for specific diagnosis or treatment details.