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https://www.fairviewdental.net/post-appointment-survey

html fairviewdental.net collected 2026-10-08 14:40:46 UTC 20,594 bytes, 246 lines download raw bytes

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10<title>Post-Appointment Survey - Fairview Dental | Aurora IL </title>
11<meta name="description" content="Fairview Dental is your Aurora, Naperville, Sugar Grove, and surrounding Fox Valley, IL dentist, providing quality dental care and Invisalign® for children, teens, and adults. Call today. ">
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43<body class="post-appointment-survey sidebar-left footer-normal nav-top layout-standard layout-section-contact-us psds">
44
45<div id="vertex">
46<div id="hd">
47    <div class="container row">
48    
49<div id="logo"><a href="/"><img src="/assets/images/logo.png" alt="fairview dental smiles with style" width="250" height="67" /></a></div> 
50
51<div class="module">
52    <div class="info">
53    <div id="contact-info">
54        <a class="phone" href="tel:630-897-1156">(630) 897-1156
55        </a><a class="addy" href="/office-location">541 Sullivan Rd, Aurora, IL 60506
56        </a></div><div class="social-media">
57    <div class="ib">
58<a class="facebook" aria-label="facebook" href="https://www.facebook.com/FAIRVIEW-DENTAL-135294169298/"><span class="fab fa-fw fa-facebook-f" aria-hidden="true"></span></a>
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63</div><!--/social-media-->    </div><!--.info-->
64    <div class="util">
65        <a class="officeLocation" href="/office-location">Contact Us
66        </a><a class="appointmentRequest" href="/appointment-request">Schedule an Appointment</a><a class="officeLocation" href="https://patient.sesamecommunications.com/gahasic1/index.html">Patient Login</a>
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79    <ul><li class="home first"><a href="/home" id="home" class="home"><span>Home</span></a></li><li class="about-us"><a href="/meet-dr-michele-bruno" id="about-us" class="about-us"><span>About</span> <span>Us</span></a><ul><li class="meet-dr-michele-bruno first"><a href="/meet-dr-michele-bruno" class="meet-dr-michele-bruno"><span>Meet</span> <span>Dr.</span> <span>Michele</span> <span>Bruno</span></a></li><li class="meet-dr-salvador-cardenas"><a href="/meet-dr-salvador-cardenas" class="meet-dr-salvador-cardenas"><span>Meet</span> <span>Dr.</span> <span>Salvador</span> <span>Cardenas</span></a></li><li class="meet-dr-david-gorenz"><a href="/meet-dr-david-gorenz" class="meet-dr-david-gorenz"><span>Meet</span> <span>Dr.</span> <span>David</span> <span>Gorenz</span></a></li><li class="meet-dr-david-dominguez"><a href="/meet-dr-david-dominguez" class="meet-dr-david-dominguez"><span>Meet</span> <span>Dr.</span> <span>David</span> <span>Dominguez</span> <span></span></a></li><li class="meet-dr-annette-rogers"><a href="/meet-dr-annette-rogers" class="meet-dr-annette-rogers"><span>Meet</span> <span>Dr.</span> <span>Annette</span> <span>Rogers</span></a></li><li class="what-sets-us-apart last"><a href="/what-sets-us-apart" class="what-sets-us-apart"><span>What</span> <span>Sets</span> <span>Us</span> <span>Apart</span></a></li></ul></li><li class="for-patients"><a href="/office-visits" id="for-patients" class="for-patients"><span>For</span> <span>Patients</span></a><ul><li class="office-visits first"><a href="/office-visits" class="office-visits"><span>Office</span> <span>Visits</span></a></li><li class="patient-forms"><a href="/patient-forms" class="patient-forms"><span>Patient</span> <span>Forms</span></a></li><li class="testimonials"><a href="/testimonials" class="testimonials"><span>Testimonials</span></a></li><li class="office-tour"><a href="/office-tour" class="office-tour"><span>Office</span> <span>Tour</span></a></li><li class="financial-information"><a href="/financial-information" class="financial-information"><span>Financial</span> <span>Information</span></a></li><li class="patient-login-portal last"><a href="https://patient.sesamecommunications.com/gahasic1/index.html" class="patient-login-portal"><span>Patient</span> <span>Login</span> <span>Portal</span></a></li></ul></li><li class="smiles-with-style"><a href="/smiles-with-style" id="smiles-with-style" class="smiles-with-style"><span>Smiles</span> <span>With</span> <span>Style</span></a></li><li class="general-dentistry"><a href="/preventive-care" id="general-dentistry" class="general-dentistry"><span>General</span> <span>Dentistry</span></a><ul><li class="preventive-care first"><a href="/preventive-care" class="preventive-care"><span>Preventive</span> <span>Care</span></a></li><li class="dental-exams-and-cleanings"><a href="/dental-exams-and-cleanings" class="dental-exams-and-cleanings"><span>Dental</span> <span>Exams</span> <span>and</span> <span>Cleanings</span></a></li><li class="gum-disease"><a href="/gum-disease" class="gum-disease"><span>Gum</span> <span>Disease</span></a></li><li class="oral-cancer-screening"><a href="/oral-cancer-screening" class="oral-cancer-screening"><span>Oral</span> <span>
79Cancer</span> <span>Screening</span></a></li><li class="tmj-tmd"><a href="/tmj-tmd" class="tmj-tmd"><span>TMJ-TMD</span></a></li><li class="emergency-dental-care"><a href="/emergency-dental-care" class="emergency-dental-care"><span>Emergency</span> <span>Dental</span> <span>Care</span></a></li><li class="pediatric-dentistry last"><a href="/pediatric-dentistry" class="pediatric-dentistry"><span>Pediatric</span> <span>Dentistry</span></a></li></ul></li><li class="cosmetic-dentistry"><a href="/cosmetic-dentistry" id="cosmetic-dentistry" class="cosmetic-dentistry"><span>Cosmetic</span> <span>Dentistry</span></a><ul><li class="cosmetic-dentistry first"><a href="/cosmetic-dentistry" class="cosmetic-dentistry"><span>Cosmetic</span> <span>Dentistry</span></a></li><li class="invisalign-treatment"><a href="/invisalign-treatment" class="invisalign-treatment"><span>Invisalign®</span> <span>Treatment</span></a></li><li class="teeth-whitening"><a href="/teeth-whitening" class="teeth-whitening"><span>Teeth</span> <span>Whitening</span></a></li><li class="veneers last"><a href="/veneers" class="veneers"><span>Veneers</span></a></li></ul></li><li class="our-procedures"><a href="/bruxism" id="our-procedures" class="our-procedures"><span>Our</span> <span>Procedures</span></a><ul><li class="bruxism first"><a href="/bruxism" class="bruxism"><span>Bruxism</span></a></li><li class="bonding"><a href="/bonding" class="bonding"><span>Bonding</span></a></li><li class="bridges"><a href="/bridges" class="bridges"><span>Bridges</span></a></li><li class="crowns"><a href="/crowns" class="crowns"><span>Crowns</span></a></li><li class="fillings"><a href="/fillings" class="fillings"><span>Fillings</span></a></li><li class="fluoride"><a href="/fluoride" class="fluoride"><span>Fluoride</span></a></li><li class="implant-restoration"><a href="/implant-restoration" class="implant-restoration"><span>Implant</span> <span>Restoration</span></a></li><li class="nitrous-oxide"><a href="/nitrous-oxide" class="nitrous-oxide"><span>Nitrous</span> <span>Oxide</span></a></li><li class="root-canals"><a href="/root-canals" class="root-canals"><span>Root</span> <span>Canals</span></a></li><li class="sealants"><a href="/sealants" class="sealants"><span>Sealants</span></a></li><li class="implants last"><a href="/implants" class="implants"><span>Implants</span></a></li></ul></li><li class="our-technology"><a href="/all-on-4" id="our-technology" class="our-technology"><span>Our</span> <span>Technology</span></a><ul><li class="all-on-4 first"><a href="/all-on-4" class="all-on-4"><span>All-on-4®</span></a></li><li class="cerec"><a href="/cerec" class="cerec"><span>CEREC®</span></a></li><li class="lumineers"><a href="/lumineers" class="lumineers"><span>Lumineers®</span></a></li><li class="opalescence"><a href="/opalescence" class="opalescence"><span>Opalescence®</span> <span></span></a></li><li class="dentures"><a href="/dentures" class="dentures"><span>Dentures</span></a></li><li class="nightguards"><a href="/nightguards" class="nightguards"><span>Nightguards</span></a></li><li class="mouthguards last"><a href="/mouthguards" class="mouthguards"><span>Mouthguards</span></a></li></ul></li><li class="contact-us active"><a href="/office-location" id="contact-us" class="contact-us"><span>Contact</span> <span>Us</span></a><ul><li class="office-location first"><a href="/office-location" class="office-location"><span>Office</span> <span>Location</span></a></li><li class="appointment-request"><a href="/appointment-request" class="appointment-request"><span>Appointment</span> <span>Request</span></a></li><li class="refer-a-friend"><a href="/refer-a-friend" class="refer-a-friend"><span>Refer</span> <span>a</span> <span>Friend</span></a></li><li class="post-appointment-survey active last"><a href="/post-appointment-survey" class="post-appointment-survey"><span>Post-Appointment</span> <span>Survey</span></a></li></ul></li><li class="email-us"><a href="mailto:[email protected]" id="email-us" class="email-us"><span>Email</span> <span>Us</span></a></li></ul>			
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90	    <div><p class="subnav"><a href="/office-location" class="office-location">Office Location</a><span class="divider"> | </span>
90<a href="/appointment-request" class="appointment-request">Appointment Request</a><span class="divider"> | </span><a href="/refer-a-friend" class="refer-a-friend">Refer a Friend</a><span class="divider"> | </span><a href="/post-appointment-survey" class="post-appointment-survey active">Post-Appointment Survey</a></p></div>
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99<div id="hide-stock"><img src="/assets/uploads/images/post-appointment-survey.jpg" class="static" alt="post appointment survey" /></div>
100<!-- Blog -->
101
102</div><!--/sidebar-->
103
104<div id="content">
105    <header><h1>Post-Appointment Survey</h1></header>
106    <div class="content-text"><p class="width2">
107	We appreciate you choosing our practice, and we are committed to making sure that your time spent with us is as comfortable and fulfilling as possible. In order to continue providing the kind of care that keeps our patients smiling, we encourage your comments and suggestions about the treatments and personal care you&#39;ve received while visiting our practice.</p>
108<p class="width2">
109	Please take a moment to provide us with your feedback. When you&#39;re finished, click on the <strong>SUBMIT</strong> button at the bottom of the page.</p>
110<form action="/post-appointment-survey" class="width2 validate" method="post">
111	<label for="Web_Address"><input id="Web_Address" name="sc_form[Web_Address]" type="hidden" /> </label> <input id="required_values" name="required_values" type="hidden" value="Contact_Patient" />
112	<fieldset>
113		<legend>Please tell us about your appointment:</legend>
114		<p class="notice width1 box-round">
115			<strong>Bold</strong> fields are required.</p>
116		<label class="first width2" for="My_Experience"><span>Please describe your experience visiting our practice.</span><textarea cols="30" id="My_Experience" name="sc_form[My_Experience]" rows="10" tabindex="1"></textarea></label> <label class="first width2" for="Experience_with_Team"> <span>Please describe your experience working with the doctor(s) and staff.</span><textarea cols="30" id="Experience_with_Team" name="sc_form[Experience_with_Team]" rows="10" tabindex="2"></textarea></label> <label class="first width2" for="Favorite_Thing_About_Practice"> <span>What was your favorite thing about being at our practice?</span><textarea cols="30" id="Favorite_Thing_About_Practice" name="sc_form[Favorite_Thing_About_Practice]" rows="10" tabindex="3"></textarea></label> <label class="first width2" for="How_Can_We_Improve"> <span>What areas could we improve upon to make your experience even more enjoyable?</span><textarea cols="30" id="How_Can_We_Improve" name="sc_form[How_Can_We_Improve]" rows="10" tabindex="4"></textarea></label>
117		<fieldset class="radio-group full">
118			<p>
119				<span>How would you rate your overall experience?</span></p>
120			<div class="full" id="rating">
121				<label class="first unitx1" for="Rating_Poor"><input id="Rating_Poor" name="sc_form[Rating]" tabindex="8" type="radio" value="Poor" /> <span>Poor</span></label> <label class="unitx1" for="Rating_Average"> <input id="Rating_Average" name="sc_form[Rating]" tabindex="7" type="radio" value="Average" /> <span>Average</span></label> <label class="unitx1" for="Rating_Good"> <input id="Rating_Good" name="sc_form[Rating]" tabindex="6" type="radio" value="Good" /> <span>Good</span></label> <label class="unitx1" for="Rating_Great"> <input id="Rating_Great" name="sc_form[Rating]" tabindex="5" type="radio" value="Great!" /> <span>Great!</span></label></div>
122		</fieldset>
123		<label class="first width2" for="Additional_Comments"><span>Please provide any additional comments/suggestions.</span><textarea cols="30" id="Additional_Comments" name="sc_form[Additional_Comments]" rows="10" tabindex="9"></textarea></label>
124		<hr />
125		<div class="hr">
126			&nbsp;</div>
127	</fieldset>
128
129
130	<fieldset>
131		<legend>Contact Information:</legend>
132		<p class="required loud first width2">
133			<span>Would you like a member of our team to contact you to further discuss your experience?</span></p>
134		<select class="width1" id="Contact_Patient" name="sc_form[Contact_Patient]" required="required"><option value="">Select an option</option><option value="Yes">Yes</option><option value="No">No thank you; see you at my next appointment.</option></select>
135	
136  
137  	<fieldset class="full hidden-option" id="survey_participant">
138			
139      
140       <legend>Please provide your name and email address:</legend>
141      
142       <label class="required first width1" for="Survey_Participant_Name"> <span>Your Name</span> 
143       
144       <input id="Survey_Participant_Name" minlength="2" name="sc_form[Survey_Participant_Name]" type="text" /> 
145       <!--disabled="disabled" -->
146       
147       <span class="quiet">First and Last</span></label> 
148       
149       <label class="required width1" for="Survey_Participant_Email"> <span>Your Email Address</span><br />
150			
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152       <!--disabled="disabled" -->
153       
154		<hr />
155		<div class="hr">&nbsp;</div>
156    
157	</fieldset>
158	
159  
160  <fieldset>
161		<button class="button button-medium site-button-color box-round box-shadow">Submit Feedback</button></fieldset>
162</form>
163</div>
164    </div><!--/content-->
165    
166    </div><!--/container-->
167</div><!--/bd-->
168
169
170
171	<div class="supervol seven"><span>Expect a modern office with the latest in dental technology.</span></div>
172
173<div id="ft" class="row">
174        
175<div id="location">
176	<img class="logo" src="/assets/images/footer/logo.png" alt="" width="301" height="107" />
177    <a class="phone" href="tel:630-897-1156">(630) 897-1156</a>
178    <a class="addy" href="/office-location"><div class="street">541 Sullivan Rd, Aurora, IL 60506</div></a>
179    <div class="util">
180    <table class="h_o_o">
181 	<tbody>
182        <tr><td>Mon</td><td>8am - 8pm</td></tr>
183        <tr><td>Tue</td><td>8am - 6pm</td></tr>
184        <tr><td>Wed</td><td>8am - 5pm</td></tr>
185        <tr><td>Thu</td><td>8am - 6pm</td></tr>
186        <tr><td>Fri</td><td>7am - 2pm</td></tr>
187        <tr><td>Sat</td><td>8am - 1pm</td></tr>
188    </tbody>	
189    </table><div class="social-media">
190    <div class="ib">
191<a class="facebook" aria-label="facebook" href="https://www.facebook.com/FAIRVIEW-DENTAL-135294169298/"><span class="fab fa-fw fa-facebook-f" aria-hidden="true"></span></a>
192<a class="google" aria-label="google" href="https://goo.gl/maps/3w3t7F4Qdcy"><span class="fab fa-fw fa-google" aria-hidden="true"></span></a>
193<a class="yelp" aria-label="yelp" href="https://www.yelp.com/biz/fairview-dental-aurora"><span class="fab fa-fw fa-yelp" aria-hidden="true"></span></a>
194<a class="healthgrades" aria-label="healthgrades" href="https://www.healthgrades.com/group-directory/il-illinois/aurora/fairview-dental-oo5vxy6"><span class="fa-fw fa-healthgrades2" aria-hidden="true"></span></a>
195    </div><!--.ib-->
196</div><!--/social-media-->    </div><!--.util-->
197    
198    <div id="links">        
199        <a id="sesame-link" class="sesame-link" href="http://www.sesamecommunications.com/web-design/">Website Powered by Sesame 24-7<sup>&trade;</sup></a>
200        <span class="divider">|</span>
201        <a class="site_map" href="/sitemap">Site Map</a>
202        <span class="divider opp">|</span>
203        <a id="back-to-top" href="#hd">Back to Top</a>
204    </div><!--/links--> 
205   
206</div><!--/location-->
207
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