PATIENT SATISFACTION QUESTIONNAIRE

Today’s Date: 7/11/2007

Dear Patient,

Have you been wanting to tell us what you think? We’d love to know! Would you please help us improve our patient care by completing this anonymous questionnaire? We welcome your comments!

I.	OFFICE STAFF AND PROCEDURES
	A.	In your initial contact by phone, were our receptionists
		-	Courteous?	Yes	No
		-	Helpful?	Yes	No
	B.	During your visits to our office, were our receptionists
		-	Friendly?	Yes	No
		-	Responsive?	Yes	No
	C.	Did the waiting time seem reasonable to you?		Yes	No

	D.	What was your source of referral to our practice? If more than one applies, please indicate order of importance.
		Family / Friend			Physician____________
		Print Media ________________			Other______________
		Website name or search engine AOL searcg for cosmetic surgery
II.	THE CONSULTATION PROCESS
	A. Was your consultation educational and helpful in understanding:
		-	the surgery to be done?	Yes	No
		-	the potential risks and complications?	Yes	No
	B.	Were all of your questions answered?
		Yes
	C.	Was accreditation of the surgeon important to you?
		Yes
	D.	Was accreditation of the facility important to you?
		Yes
	E.	What do you think of our brochure and letters?
		VERY INFORMATIVE. SEEMED TO ADDRESS ANY QUESTION THAT MAY ARISE.
	F.	Did you consider any other plastic surgery office? Yes No
		If yes, why did you choose our office rather than the others?
		If no, why did you only consider our office?
		After researching other doctors and offices to perform my surgery, i found dr cohen best suited to handle my procedure. I also referred a friend and she got her procedure done 6 mos. Before me. She was very pleased. I had, then, first hand experience right there. Someone that i knew to give me her experience. I also liked the website. The feel of the office.
III.	STAFF AND SURGERY SCHEDULING
	A. In your initial visit to our office, was our staff:
		-	Informative?	Yes	No
		-	Caring?	Yes	No
		-	Professional?	Yes	No
	B. Were your financial arrangements made in a professional and unembarrassing manner?
		Yes
	C.	After the surgery was scheduled, did the amount of contact by the staff meet your pre-operative needs?
		Yes!!
	D.	Do you feel the staff was easily accessible if you had a question or concern?
		Yes
	E.	What did you think about the pre-operative package and post-op instructions?
		Very helpful
	F.	Is there anything the staff could have done to improve your experience?
		No, my every pre & post operative need was met.
IV.	PHYSICIAN AND SURGERY
	A.	Was your surgeon
		-	Knowledgeable?	Yes	No
		-	Caring?	Yes	No
		-	Thorough?	Yes	No
		-	Professional?	Yes	No
		-	Patient?	Yes	No
	B.	Did your pre and post-operative care meet your needs?
		Yes
	C.	How do you feel about your surgical result?
		Very pleased!
	D.	Is there anything your surgeon could have done to improve your experience?
		No
V.	FOLLOW UP
	A.	If there were a need for you to have plastic surgery again, would you return to our office?
		Yes
	B	Do you recommend our office to your friends or relatives considering plastic surgery?
		I have and will recommend your office to friend, relatives & co-workers.
VI.	We welcome your comments and suggestions:
	My experience was a memorable one. I felt very comfortable with the staff, and my doctor, Dr. Cohen, is a wonderful, skilful Doctor and his staff is the best. I was well cared for during my experience post and pre at the cosmetic center. I will recommend everyone that I know who may be interested in cosmetic surgery to Dr. Cohen.


	Name (optional):______________________

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