Patient Post-Consult Questionnaire

1. As a result of your experience with our office, please indicate which of the following best describes your feelings or concerns. You may check more than one.
2. I am very satisfied with the information I received at my consultation. I am still trying to decide whether or not to have surgery. My family and/or friends discouraged me. I need more information. I decided to postpone surgery indefinitely. I have concerns. I plan to schedule an appointment in the future. I have chosen another surgeon.
3. What would you like to know more about?
4. Please let us know your concerns and how we might address them.
5. If you plan to scheduled an appointment in the future
6. please indicate the approximate date:
7. Are you satisfied with our practice?
8. Is accreditation of the facility important to you? Yes No
9. Is accreditation of the surgeon important to you? Yes No
10. Were you pleased with the phone handling or reception? Yes No
11. Do you feel the staff was easily accessible if you had a question or concern? Yes No
12. Were you pleased with the Patient Coordinator/Scheduling interview? Yes No
13. Did the Consultation with the physician meet your needs? Yes No
14. If you decided to have surgery elsewhere...
15. If you have scheduled a surgery with another surgeon
16. Please indicate surgery date:
17. If you decided to have surgery elsewhere, please indicate the most important factors in that decision. Someone close to me recommended another surgeon. The surgeon and I failed to establish a rapport. I felt uncomfortable with the facility. The cost was too great. The financing options discussed with me were inadequate.
18. If someone recommended another surgeon to you, who made the recommendation? physician friend family
19. We are particularly interested in knowing your reaction to our communications with you. Were you happy with...
20. Consult Information Yes No
21. Post-Consultation Follow-up Yes No Did not receive
22. What was your source of referral to our office?
23. In your initial contact by phone was our staff courteous and helpful? Yes No
24. During your visit to our office was our staff friendly and responsive? Yes No
25. Did the waiting time seem reasonable to you? Yes No
26. What do you think of our brochures and letters?
27. Was your consultation educational and helpful in understanding the potential risks? Yes No
28. Were all of your questions answered? Yes No
29. Was your consultation educational and helpful in understanding the surgery? Yes No
30. How would you rate our contact with you? About Right Too much Need more
31. We welcome your comments and suggestions.
32. Comments:
33. Suggestions:
34. Your Contact Information (optional)
35. Name
36. Email
37. Telephone
38. Consult Date
39. Today’s Date

 

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Call our Algonquin, Illinois plastic surgery office at 847-458-8808 to schedule your personal consultation with board certified plastic surgeon Dr. Thors.