Mohs Micrographic Surgery Patient Survey

Please help us to continue to improve the care we provide by completing the following brief survey. We wecome your comments and encourage you to let us know how we are doing.

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* 1. Please rate the following:

	POOR	FAIR	GOOD	EXCELLENT	N/A
Was your preoperative consultation appointment scheduled in a timely manner?	Was your preoperative consultation appointment scheduled in a timely manner? POOR	Was your preoperative consultation appointment scheduled in a timely manner? FAIR	Was your preoperative consultation appointment scheduled in a timely manner? GOOD	Was your preoperative consultation appointment scheduled in a timely manner? EXCELLENT	Was your preoperative consultation appointment scheduled in a timely manner? N/A
Were treatment options given?	Were treatment options given? POOR	Were treatment options given? FAIR	Were treatment options given? GOOD	Were treatment options given? EXCELLENT	Were treatment options given? N/A
Did you feel like a partner in making your healthcare decisions?	Did you feel like a partner in making your healthcare decisions? POOR	Did you feel like a partner in making your healthcare decisions? FAIR	Did you feel like a partner in making your healthcare decisions? GOOD	Did you feel like a partner in making your healthcare decisions? EXCELLENT	Did you feel like a partner in making your healthcare decisions? N/A
Were you comfortable with the coordination of care with your plastic surgeon and/or referring physician? (if applicable)	Were you comfortable with the coordination of care with your plastic surgeon and/or referring physician? (if applicable) POOR	Were you comfortable with the coordination of care with your plastic surgeon and/or referring physician? (if applicable) FAIR	Were you comfortable with the coordination of care with your plastic surgeon and/or referring physician? (if applicable) GOOD	Were you comfortable with the coordination of care with your plastic surgeon and/or referring physician? (if applicable) EXCELLENT	Were you comfortable with the coordination of care with your plastic surgeon and/or referring physician? (if applicable) N/A
Were you comfortable during the procedure?	Were you comfortable during the procedure? POOR	Were you comfortable during the procedure? FAIR	Were you comfortable during the procedure? GOOD	Were you comfortable during the procedure? EXCELLENT	Were you comfortable during the procedure? N/A
Were you happy with your follow up care?	Were you happy with your follow up care? POOR	Were you happy with your follow up care? FAIR	Were you happy with your follow up care? GOOD	Were you happy with your follow up care? EXCELLENT	Were you happy with your follow up care? N/A

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* 2. Was the exam/operating room clean and comfortable?

Yes

No

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* 3. Were all of your questions and concerns addressed?

Yes

No

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* 4. Were you happy with the treatment you received?

Yes

No

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* 5. Was the payment expected or insurance information handled appropriately?

Yes

No

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* 6. Would you recommend Advanced Dermatology and Mohs Surgery to your friend and/or family?

Yes

No

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* 7. What can we do to improve your next visit with us?

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* 8. Additional comments:

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* 9. Name: (optional)