Consultation Survey

Thank you so much for coming in to our office for a Plastic Surgery Consultation! We hope that you enjoyed your experience as much as we enjoyed having you. Thank you for taking time out of your busy day to complete this brief survey. It is our goal to improve the care of patients each and every day–your input will help us accomplish that goal.

do or do not , there is no try check that box

How did you find out about Dr. Mills? (check all that apply)

Physician Referral

Friend/Patient

Yellow Pages

Medical Society

Internet

When you called to schedule a consultation how soon was an appointment available?

Did you visit other doctors for consultations before seeing Dr. Mills?

Yes

What factors affected your decision to consult with Dr. Mills? (check all that apply)

Office is convenient to home/work

Certified by the American Board of Plastic Surgery

Other

How would you rate the service and attention of our front office staff?

Excellent

Good

Fair

Poor

Were you seen at your scheduled appointment time? If not, how long was your wait time?

Date of consultation

What procedure(s) did you discuss with Dr. Mills?

Do you feel you were quoted a reasonable price?

Yes

Would you recommend Dr. Mills to friends and family who are considering plastic surgery?

Yes

Reason

Will you be scheduling surgery with Dr. Mills?

Yes

Undecided

If you chose not to proceed with surgery, why?

Other (please explain)

Which of the following expresses your sentiments about today’s experience with Dr. Mills’ office?

Pleased with my experience, met my expectations

Satisfied with my experience

Poor experience, did not meet my expectations

We are always striving to provide the best care to our patients, please feel free to add comments about your experience at our office. Thank you.

Name

Phone Number

Thank you for taking the time to respond. Your survey will go into a monthly drawing for skin care services.