Please select one to ten (1=Not likely at all, 10=Very likely)

HOW LIKELY ARE YOU TO REFER US TO YOUR FRIENDS AND FAMILY: 1 2 3 4 5 6 7 8 9 10

For each section, please select one to five (1=very poor, 2=needs some work, 3=average, 4=very good, 5=beyond my expectations)

Initial Contact

Phone call handling by our Appointment Coordinator: 1 2 3 4 5 Initial phone conversation with Patient Coordinator: 1 2 3 4 5

First Visit to the Office

Impression of our reception area, office decor, and cleanliness: 1 2 3 4 5 Treatment by our Receptionists: 1 2 3 4 5 Waiting Time: 1 2 3 4 5 Consultation With The Doctor: 1 2 3 4 5 Brochures and Letters: 1 2 3 4 5 Financial Options: 1 2 3 4 5

Surgery Scheduling

Waiting time until surgery: 1 2 3 4 5 Information received at preoperative visit by Patient Coordinator: 1 2 3 4 5 Risks fully explained: 1 2 3 4 5 Post-operative care fully explained: 1 2 3 4 5 Instruction Packages: 1 2 3 4 5

Surgery

Surgery Center Care: 1 2 3 4 5 Anesthesia Care: 1 2 3 4 5

Post Operative Care

Post-Operative Care: 1 2 3 4 5 Amount of Contact From Our Office Post Op: 1 2 3 4 5 Surgical Results: 1 2 3 4 5

Suggestions

Suggestions to improve how we handled your initial contact with our office... Suggestions to improve how your consultation went... Suggestions to improve your preoperative visit and Surgery Center care... Suggestions to improve your post-operative care... Would you like to become a member of our VIP Club?: Yes No Would you use us again and recommend your friends to us?: Yes No We would greatly appreciate it if you could write a small summary below of how you felt about your doctor and our office that we could post to our website and other internet review sites on your behalf (anonymously, of course!) Sign me up for the Monthly Newsletter

Thank you for taking the time to complete this questionnaire. The information you have provided will help us ensure the safe practice of plastic surgery.