In an effort to assure quality patient care in our office, we would appreciate you completing the following questionnaire and returning it to us.

Survey Form

Did our providers and staff explain your condition and/or procedure to your satisfaction? *

Yes

No

Did you receive a phone call or voicemail reminding you of today’s appointment? *

Yes

No

Did your appointment begin at a reasonable time? *

Yes

No

Did the staff answer your questions sufficiently? *

Yes

No

Were your calls returned in a timely manner, if applicable? *

Yes

No

Would you recommend our practice to your friends and family? *

Yes

No

If you answered no to any of the above questions, please explain how we can improve:

Please rate the following:

Personal attention during visit *

Excellent

Good

Fair

Poor

N/A

Friendliness and courtesy of the staff *

Excellent

Good

Fair

Poor

N/A

Professionalism and efficiency of the staff *

Excellent

Good

Fair

Poor

N/A

Protection of personal information *

Excellent

Good

Fair

Poor

N/A

Clarity of instructions given *

Excellent

Good

Fair

Poor

N/A

Cleanliness of the office *

Excellent

Good

Fair

Poor

N/A

Overall quality of care *

Excellent

Good

Fair

Poor

N/A

If you had Mohs surgery today, were you satisfied with the procedure and the physician’s ability to address your questions and concerns? *

If you were seen for a general, non-surgical skin concern, were all of your questions answered? *

If you had a cosmetic procedure today, were you satisfied with the results? *

Is there a member (or members) of our staff that you would like to recognize for being especially helpful? *

In comparison with other specialists you’ve seen, was your experience in our office better or worse? *

Additional Comments: *

Name (optional):

May we use your comments on our website? (https://www.johnvinemd.com) *

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