Chernoff Cosmetic Surgery Patient Testimonial 3:
Dear Patient:
Have you been wanting to tell us what you think? We really would love to know! Will you please help us improve our patient care by completing this anonymous questionnaire? We welcome your comments. We are enclosing a self addressed, stamped envelope for your convenience.
I. Office Staff and Procedures Indianapolis Plastic Surgery Patient Testimonial 3
A. In your initial contact by phone, were our staff members:
Courteous? Yes_X No___
Helpful? Yes_X_ No___
Knowledgeable? Yes_X_ No___
B.
During your visit to the office, were our receptionists and staff:
Friendly? Yes_X_ No___
Responsive? Yes_X_ No___
C.
Were you made to feel comfortable and welcome? Yes_X_ No___
D.
Did you waiting time seem reasonable to you? Yes_X_ No___
E.
What was your source of referral to our practice? If more than one, please indicate in order of importance:
Family/Friend _____________ Physician _________
Print/TV __________________ Salon ____________
Yellow pages/Internet ________
Dr. Chernoff was a former customer of our computer system. (Prism Data Systems)
II. The Consultation Process
A Was your consultation educational and helpful in understanding:
The surgery or procedure to be done? Yes_X_ No___
Potential risks or complications? Yes_X_ No___
B Were all your questions answered to your satisfaction? Yes_X_ No___
C Was accreditation of the surgeon important to you? Yes_X_ No___
D Was accreditation of the facility important to you? Yes_X_ No___
E What do you think of our brochures and letters?
__Very informative ______________________________________________
F Did you consider another plastic surgery office? Yes_X_ No___
If yes, why did you choose our office rather than the others?
______________________________________________________________
If no, why did you consider only our office?
__Anette Bracket works as a surg nurse & I know her & trust her judgment._
III. Follow Up
A In your initial visit to our office, were our nurses/staff:
Informative? Yes_X_ No___
Caring? Yes_X_ No___
Professional? Yes_X_ No___
B Will you be returning to our offices for further treatments? Yes_X_ No___
C Would you recommend us to family and friends? Yes_X_ No___
If NO, would you briefly tell us why?
My results are so wonderful & I would do it again although I would never need it –
it’s so great now. Everything Dr. Chernoff said about how people would take it was
true __________________________________________________
E-mail address: ________________________________________________________
Signature: ___________________________________________________________
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Chernoff Cosmetic Surgery
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