Record of Experience Patient Feedback Form NEBDN

The involvement of patients in the assessment of dental nursing practice is highly valued. Therefore,
we would be grateful if you would consider providing comments overleaf on the care that you have
received from the student nurse named below. This information will contribute to ‘practical
assessment’ as part of the student’s training and will be retained as evidence in the student’s
portfolio. Feedback will be treated in confidence and will not affect your care. Your care will also not
be affected should you chose not to complete this feedback form. Please answer the following
questions relating to the student dental nurse.

Student Dental Nurse Name:

About you:
Age: Gender: Male ☐ Female ☐
New Patient
Type of Emergency Regular
Appointmen ☐ ☐ ☐
Visit: Appointment Appointment
t
Date of Visit:
About your care:
Yes No N/A
The Dental Nurse treated me with respect ☐ ☐ ☐
The Dental Nurse communicated well ☐ ☐ ☐
The Dental Nurse listened to whatever I had to say ☐ ☐ ☐
The Dental Nurse is caring and friendly ☐ ☐ ☐
I am confident the Dental Nurse is competent in their role ☐ ☐ ☐
The Dental Nurse had a professional appearance ☐ ☐ ☐
The Dental Nurse behaved in a professional manner ☐ ☐ ☐
The Dental Nurse and Dentist work well as a team ☐ ☐ ☐

Please record below any further comments or suggestions for improvement.

If you do choose to complete this feedback form, please hand it to the student dental nurse on
completion.

Thank you for your time.