SkinStim Patient Satisfaction Survey Name First Last Email* PhoneDate of Service MM slash DD slash YYYY In order to better serve your future needs, we’d like to know about your experience with our office today. Please, kindly take a few minutes to rate the following statements.I was given the appointment time and date that I requested:Strongly AgreeAgreeDisagreeStrongly DisagreeAll my questions (if any) were answered to my satisfaction prior to my appointment:Strongly AgreeAgreeDisagreeStrongly DisagreeMy provider adequately explained my treatment to me including potential risks:Strongly AgreeAgreeDisagreeStrongly DisagreeI would recommend SkinStim and the Providing Clinic to a friend or relative.Strongly AgreeAgreeDisagreeStrongly DisagreeOn a scale of 1 to 10, with 10 being the best, how would you rate your overall experience today? (Please check one)12345678910On this scale tell us your level of overall satisfaction with the SkinStim treatment compared to expectations...5 Stars ***** 100% = Result exceeded expectations delighted.4 Stars **** 85% = Good result quite satisfied.3 Stars *** 65% = Satisfied but not delighted.2 Stars ** 35% = Satisfied somewhat.1 Star * 0% = Not satisfied at all.1 Star * 0% = Not satisfied at all. 2 Stars ** 35% = Satisfied somewhat. 3 Stars *** 65% = Satisfied but not delighted. 4 Stars **** 85% = Good result quite satisfied. 5 Stars ***** 100% = Result exceeded expectations delighted. Additional Comments: Please let us know your comments and/or suggestions and what you liked or disliked about your experience here with us today:
