Patient Survey

Please assist us in improving our service and the efficiency of our office. Take a moment to complete the brief survey below. You will be entered into a drawing to win a complimentary Botox® session or Spaderma services of equal value.

Your name/phone number below will be removed for the drawing before surveys are submitted for review.
*ME- Medical Estheticians/Spaderma

Survey Question
Poor
Fair
Good
Very Good
Excellent
Ease of scheduling appointments
Office environment cleanliness, comfort, location  
Office staff friendliness and courtesy  
Wait time before seeing physician  
Wait time before seeing medical esthetician  
Listens and Answers Questions

Dr. Simo

ME

 

 

 

Helps you understand your medical conditions

Dr. Simo

ME
Spends an appropriate amount of time with you

Dr. Simo

ME
You trust physician's/ME decision/recommendations in the your best interest

Dr. Simo

ME
You would recommend physician/ME to family/friends

Dr. Simo

ME

          
Interested in Saturday Hours
Or Late Hours

Dr. Simo

ME

          


Please make any comments: (Use second page, if necessary)

 

 
I am interested in learning about body contouring procedures.            
I am interested in having surgery to improve or correct other areas of the body. (Other than Face)            

First Name Only: ________________Phone Number ______________ or Email: ____________________________________

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