Total Dermatology Visit Satisfaction
Page One
Thank you for taking our questionnaire.
It will take only a minute or 2 to complete. We appreciate your business and value your opinion. We’ll use your responses to evaluate how well we are taking care of our patients and to make improvements where needed.
All your answers are confidential and help us to serve you better.
1.
Was your visit to Total Dermatology for a medical or cosmetic purpose?
Medical
Cosmetic
Both
Consultation Only
2.
Please rate our reception staff
Courteous and Helpful
Average
Below Average
Poor
3.
Our reception and medical staff are the backbone of our practice. If during your visit members of our staff made you feel particularly welcome or well treated, please let us know.
Heather (Reception)
Phuong (Reception)
Maria (Med Assistant & Reception)
Vera (Nurse)
Joanne (Nurse)
Laura (Laser Nurse)
Minoo (Esthetician)
Mariah ( Manager)
4.
If you've selected a name (or names) above, is there anything in particular you would like to share about your interaction?
5.
Scheduling - Were we on time?
Yes, I was seen promptly
I waited more than 15 minutes past my scheduled time
I waited more than 30 minutes past my scheduled time
I waited more than 45 minutes past my scheduled time
6.
Was there anything about your visit that you were not totally satisfied with? If so, what improvements do you feel should be made?
7.
Who provided your treatment or consultation for this visit? (Choose all who apply)
Dr. Pilest
Laser Nurse
Esthetician
Manager
8.
Did you receive enough printed educational materials to take home?
Yes
No, I needed more printed material
Was not given any brochures
9.
Were you able to spend as much time with the doctor or nurse as you expected or needed?
Enough time
Time with doctor too brief
Time with nurse too brief
Felt rushed
10.
Based on how you were treated during this visit, would you recommend us ?
Yes
No
11.
If you had a particularly positive visit or procedure outcome, would you share with us so we may post your comments? If so, please also add your first name or initials.
12.
If your visit was for a consultation, did you make an appointment?
Yes
No
13.
If the answer to the last question was No, what made you decide against becoming a patient?
Too expensive
Was not convinced the treatment would work for me
Felt there was too much pressure
Didn't fully understand the recommendations
Wanted to visit another practice before deciding
14.
Please add your contact information if you would like us to follow up with you. This is not a requirement. Your response can remain anonymous if you prefer.
Email Address
Name
Phone #
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