As a result of your experience with our office, please indicate which of the following best describes your feelings or concerns. Select all that apply:

I am very satisfied with the information I received at my consultation.
I am still trying to decide whether or not to have surgery.
My family and/or friends discouraged me. I need information about: I decided to postpone my surgery indefinitely I am concerned about: I plan to schedule an appointment in the future. Please indicate an approximate time: I have chosen another surgeon. Please indicate surgery date: Comments:

Are you satisfied with our practice?

Phone handling or reception: Satisfied Not Satisfied Nurse: Satisfied Not Satisfied Patient coordinator: Satisfied Not Satisfied Consultation with physician: Satisfied Not Satisfied Comments:

If you decided to have surgery elsewhere, please indicate the most important factors in that decision.

Another surgeon was recommended by: Physician Friend(s) Family
The surgeon and I failed to establish a rapport.
I felt uncomfortable with the facility.
The price was too high.
The financing options discussed with me were inadequate.

We are particularly interested in knowing your reaction to our communications with you. Were you happy with:

Pre-consult information: Satisfied Not Satisfied Did not receive Post-consult follow-up: Satisfied Not Satisfied Did not receive

How would you rate our contact with you?

About right Too Much Need More

We welcome your comments and suggestions: