FEEDBACK FORM

Please answer any questions that apply to your procedure. Our intentions are to ensure you have a great experience with us. We appreciate your honesty and value your feedback.

Your Name:
Email:
Phone:
Home Address:
Apt/Unit:
City:
State:
Zip:
Service or procedure performed:
Were you properly greeted? YesNoDon't recall
Were you offered a complimentary drink? YesNoDon't recall
Was the temperature comfortable? YesNoDon't recall
Were all of your questions properly answered when you scheduled this appointment? YesNoDon't recall
Were there any problems with Check In/Out?
If yes, please explain:		 YesNoDon't recall
Did you feel a warm & welcoming atmosphere upon entering? YesNoDon't recall
Do you feel that your privacy was respected while at our office or in the waiting area? YesNo
Did your service provider conduct a thorough consultation on cosmetic procedures and skincare available to help you achieve your goals? YesNo
Were you informed of our SkinMedica Savvy Shopper Rewards program? YesNo
Were you informed of our current special offers? YesNo
Were you invited to secure your next appointment? YesNo
Were you offered a complimentary skin care consultation, Image Pro skin analysis or makeup touch up? YesNo
Do you feel confident you have a complete understanding of how to apply your new skincare regimen once you get home? YesNo
Were you given brochures on procedures or skincare that meet your desired skincare goals? YesNo
If you have not met with Dr. Seiler yet, would you like a consultation with him on your next visit? YesNo
If you have met with him before, would you like to make an appointment to talk with Dr. Seiler about a new skin concern? YesNo
Please rate your service provider’s overall performance   1 2 3 4 5 6 7 8 9 10
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Were you pleased with your results? YesNo
Were you given post procedure instructions? YesNo
How did you find us? Please explain how you heard about us.
Did you have any trouble finding us or with parking? YesNoDon't recall
Please rate the overall atmosphere   1 2 3 4 5 6 7 8 9 10
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If you viewed our website www.seilerskin.com before your appointment today, did you find it easy to navigate with all the information you needed? YesNo
Would you refer us to one of your friends? YesNo
Are there any services or procedures we currently do not offer which you would like to have available?
Is there any service, cosmetic laser procedure, or aesthetic treatment you would like to receive more information on?
Are there any additional comments you would like to share with our management?