Patient Survey

Please assist us in improving our service and the efficiency of our office. Take a moment to complete the brief survey below. You will be entered into a drawing to win a complimentary Botox® session or Spaderma services of equal value.

Your name/phone number below will be removed for the drawing before surveys are submitted for review

*ME- Medical Estheticians/Spaderma

Survey Questions

Ease of scheduling appointments
Poor	Fair	Good	Very Good	Excellent
Office environment cleanliness, comfort, location
Poor	Fair	Good	Very Good	Excellent
Office staff friendliness and courtesy
Poor	Fair	Good	Very Good	Excellent
Wait time before seeing physician
Poor	Fair	Good	Very Good	Excellent
Wait time before seeing medical esthetician
Poor	Fair	Good	Very Good	Excellent
Listens and Answers Questions
Poor	Fair	Good	Very Good	Excellent
Helps you understand your medical conditions
Poor	Fair	Good	Very Good	Excellent
Spends an appropriate amount of time with you
Poor	Fair	Good	Very Good	Excellent
You trust physician's/ME decision/recommendations in the your best interest
Poor	Fair	Good	Very Good	Excellent
You would recommend physician/ME to family/friends
Poor	Fair	Good	Very Good	Excellent
Interested in Saturday Hours or Late Hours
Poor	Fair	Good	Very Good	Excellent
Ease of scheduling appointments
Poor	Fair	Good	Very Good	Excellent
I am interested in learning about body contouring procedures.
Yes	No
I am interested in having surgery to improve or correct other areas of the body. (Other than Face)
Yes	No

First Name Only:
Phone Number:
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