1<!DOCTYPE html> 2<!--[if lt IE 7]> <html lang="en" class="lt-ie10 lt-ie9 lt-ie8 lt-ie7"> <![endif]--> 3<!--[if IE 7]> <html lang="en" class="ie7 lt-ie10 lt-ie9 lt-ie8"> <![endif]--> 4<!--[if IE 8]> <html lang="en" class="ie8 lt-ie10 lt-ie9"> <![endif]--> 5<!--[if IE 9]> <html lang="en" class="ie9 lt-ie10"> <![endif]--> 6<!--[if gt IE 9]><!--> <html lang="en"> <!--<![endif]--> 7 8<head> 9<meta charset="utf-8"> 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. "> 12<meta name="HandheldFriendly" content="True"> 13<meta name="MobileOptimized" content="320"> 14<meta name="viewport" content="width=device-width, user-scalable=0"> 15<meta name="format-detection" content="telephone=no"/> 16<!--[if IEMobile]> <meta http-equiv="cleartype" content="on"> <![endif]--> 17 18 19<!-- Standard desktop and mobile favicons --> 20<link rel="shortcut icon" href="/assets/images/icons/favicon.png"> 21 22<!-- CSS Stylings (Default Base Stylings and Site Specific) --> 23<link rel="stylesheet" href="//srwd.sesamehub.com/assets/fonts/font-awesome-pro-5.2.0/css/all.min.css"> 24<link rel="stylesheet" href="//srwd.sesamehub.com/assets/v5.0/global.min.css"> 25<link rel="stylesheet" href="/assets/css/local.css"> 26 27<!-- Javascript Libraries -->
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40 41</head> 42 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> 59<a class="google" aria-label="google" href="https://goo.gl/maps/3w3t7F4Qdcy"><span class="fab fa-fw fa-google" aria-hidden="true"></span></a> 60<a class="yelp" aria-label="yelp" 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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> 91 92 </div><!--/container--> 93</div><!--/ip-sub--> 94 95<div id="bd"> 96 <div class="container row"> 97 98<div id="sidebar"> 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've received while visiting our practice.</p> 108<p class="width2"> 109 Please take a moment to provide us with your feedback. When you'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 </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 /> 150 151 <input id="Survey_Participant_Email" name="sc_form[Survey_Participant_Email]" type="email" /></label></fieldset> 152 <!--disabled="disabled" --> 153 154 <hr /> 155 <div class="hr"> </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>™</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--> 207 208</div><!--/ft--> 209 210 211 212 213<!-- Additional scripts (Mobile Helpers, Console Detector, etc) --> 214<!-- Cycle2 Javascript file -->
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