Consultation Experience Survey Nashville

Step 1 of 7

14%

Please select the location of your most recent visit to our practice:*(Required)

Franklin (Cool Springs)

Nashville (Music Row)

Mt. Juliet

Brentwood

Please select the provider you saw:*(Required)

Dr. John R. Moore

Dr. Konrad Sarosiek

What was the key reason(s) you chose our practice for your consultation? (Choose all that apply)*(Required)

Friend/Family Referral

Physician Referral

Website

Social Media

Reputation/Experience

Information Provided to Me

Magazine or Newspaper Ad

Cost

Facility / Office

Location

Seminar

Search Engine

Already a Patient

Receptionist & Waiting Room Experience

When you arrived at the office, how would you rate the RECEPTIONIST in the following areas: Friendly & Courteous?*(Required)

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Please Explain:

Helpful?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

How acceptable was the amount of time spent in the reception area and exam room, before being seen for your consultation?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

Comments

Staff & Nurse Experience

During your consultation, how would you rate our STAFF & NURSES in the following areas? Friendly & Courteous?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

Competent & Professional*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

Sympathetic & Caring?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

Comments

Doctor Experience

During your examination, how would you rate the DOCTOR in the following areas? Friendly & Courteous?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

Competent & Professional?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

Sympathetic & Caring?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

Please Explain:

Any Comments?

Please rate your satisfaction with the amount of time the DOCTOR spent with you to answer questions, explain procedures and treatment options.*(Required)

Very Satisfied

Satisfied

Neutral

Displeased

Very Displeased

N/A

Please Explain:

Please rate your satisfaction with the doctors recommendations.*(Required)

Very Satisfied

Satisfied

Neutral

Displeased

Very Displeased

N/A

Please Explain:

If a procedure was recommended, please rate your satisfaction with the manner in which the doctor discussed details and information regarding the need for the recommended procedure(s).*(Required)

Very Satisfied

Satisfied

Neutral

Displeased

Very Displeased

N/A

Please Explain:

Do you feel you were given adequate information about:* The Overall Procedure(Required)

Yes

N/A

Please Explain:

Total Fees*(Required)

Yes

N/A

Please Explain:

Procedural Risk*(Required)

Yes

N/A

Please Explain:

Procedure Results*(Required)

Yes

N/A

Please Explain:

Post-Procedure Care*(Required)

Yes

N/A

Please Explain:

Post-Consult & Quote Experience

Share with us your experience after the doctor consultation, specifically when you were discussing fees and receiving your quote. Friendly & Courteous?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

N/A

Please Explain:

Helpful?*(Required)

Excellent

Very Good

Good

Average

Fair

Poor

N/A

Please Explain:

Did you schedule a procedure during your consultation?(Required)

Yes

Not at this time, but I plan to schedule with your practice

N/A

Please Explain:

Overall Office Experience

Were you satisfied with your overall experience at our office?*(Required)

Very Satisfied

Satisfied

Neutral

Displeased

Very Displeased

N/A

Please Explain:

Do you have any comments regarding specific staff interactions and/or ideas to improve our service?

How likely is it that you would recommend Cool Springs Plastic Surgery to a friend or colleague?*(Required)

10 - Extremely likely

0 - Not at all likely

N/A

Please Explain:

This field is for validation purposes and should be left unchanged.

Survey – Consultation Experience

Receptionist & Waiting Room Experience

Staff & Nurse Experience

Doctor Experience

Post-Consult & Quote Experience

Overall Office Experience

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