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<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title>Dr. David E. Martin - Patient Satisfaction Survey</title>
</head>
<body background="images/background/rough_blue.gif" topmargin="0" leftmargin="0">
<H1 ALIGN="RIGHT"> <FONT FACE="Verdana, Arial, Helvetica, sans-serif" COLOR="#000066">
<A HREF="index.html"><IMG SRC="images/buttons/go_home.gif" WIDTH="125" HEIGHT="43" ALIGN="LEFT" BORDER="0"></A>Customer
Survey </FONT> </H1>
<form method="POST" action="http://www.dmartin.com/cgi-bin/af.cgi">
<input type="hidden" name="_send_email1" value="email.txt">
<input type="hidden" name="_out_file" value="logfile.txt">
<input type="hidden" name="_error_path" value="error.txt">
<input type="hidden" name="_browser_out" value="output.txt">
<FONT FACE="Verdana, Arial, Helvetica, sans-serif" COLOR="#000066">
</FONT>
<div align="left">
<table border="0" width="100%" cellspacing="0" cellpadding="5">
<tr>
<td valign="top" align="left" width="100"><IMG SRC="images/misc/spacer.gif" WIDTH="100" HEIGHT="10"></td>
<td valign="MIDDLE" align="CENTER" COLSPAN="3"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" COLOR="#000066" SIZE="+1"><B><I>We
Value Your Opinion!</I></B></FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100" ROWSPAN="3"></td>
<td valign="top" align="left" ROWSPAN="3"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Date
of your consult:</FONT></td>
<td valign="MIDDLE" align="RIGHT">
<p align="RIGHT"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Month</FONT>
</td>
<td valign="MIDDLE" align="LEFT"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<SELECT SIZE="1" NAME="month">
<OPTION>January</OPTION>
<OPTION>February</OPTION>
<OPTION>March</OPTION>
<OPTION>April</OPTION>
<OPTION>May</OPTION>
<OPTION>June</OPTION>
<OPTION>July</OPTION>
<OPTION>August</OPTION>
<OPTION>September</OPTION>
<OPTION>October</OPTION>
<OPTION>November</OPTION>
<OPTION>December</OPTION>
</SELECT>
</FONT></td>
</tr>
<tr>
<td valign="MIDDLE" align="RIGHT"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
Day</FONT></td>
<td valign="MIDDLE" align="LEFT"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<SELECT SIZE="1" NAME="Day">
<OPTION>1</OPTION>
<OPTION>2</OPTION>
<OPTION>3</OPTION>
<OPTION>4</OPTION>
<OPTION>5</OPTION>
<OPTION>6</OPTION>
<OPTION>7</OPTION>
<OPTION>8</OPTION>
<OPTION>9</OPTION>
<OPTION>10</OPTION>
<OPTION>11</OPTION>
<OPTION>12</OPTION>
<OPTION>13</OPTION>
<OPTION>14</OPTION>
<OPTION>15</OPTION>
<OPTION>16</OPTION>
<OPTION>17</OPTION>
<OPTION>18</OPTION>
<OPTION>18</OPTION>
<OPTION>20</OPTION>
<OPTION>21</OPTION>
<OPTION>22</OPTION>
<OPTION>23</OPTION>
<OPTION>24</OPTION>
<OPTION>25</OPTION>
<OPTION>26</OPTION>
<OPTION>27</OPTION>
<OPTION>28</OPTION>
<OPTION>29</OPTION>
<OPTION>30</OPTION>
<OPTION>31</OPTION>
</SELECT>
</FONT></td>
</tr>
<tr>
<td valign="MIDDLE" align="RIGHT"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
Year</FONT></td>
<td valign="MIDDLE" align="LEFT"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<SELECT SIZE="1" NAME="Year">
<OPTION>1998</OPTION>
<OPTION>1999</OPTION>
<OPTION>2000</OPTION>
<OPTION>2001</OPTION>
<OPTION>2002</OPTION>
</SELECT>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC">
<p align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">What
was it that made you come to our office?&nbsp;</FONT></p>
<p>&nbsp;
</td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<textarea rows="4" name="Why" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">How
was our telephone etiquette?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<textarea rows="2" name="TelephoneEtiquette" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Were
you greeted in a friendly, timely, and professional manner in our office?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" name="Greeting" CHECKED>
Yes
<input type="radio" name="Greeting" value="No">
No</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100" ROWSPAN="3"></td>
<td valign="top" align="left" ROWSPAN="3"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Who
was your consultant?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2">
<P><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<input type="radio" name="Consultant" value="Linda Doros">
Linda Doros</FONT> </P>
</td>
</tr>
<tr>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<INPUT TYPE="radio" NAME="Consultant" VALUE="Pam Cadle">
Pam Cadle</FONT></td>
</tr>
<tr>
<td valign="MIDDLE" align="left" COLSPAN="2"> <FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<INPUT TYPE="radio" NAME="Consultant" VALUE="Other">
Other </FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Did
your consultant conduct themselves in a professional manner?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" CHECKED name="Conduct">
Yes
<input type="radio" name="Conduct" value="No">
No
<INPUT TYPE="radio" NAME="Conduct" VALUE="No Opinion">
No Opinion</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Did
they spend enough time with you?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<input type="radio" value="Yes" name="TimeSpent" CHECKED>
Yes
<input type="radio" name="TimeSpent" value="No">
No </FONT><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<INPUT TYPE="radio" NAME="TimeSpent" VALUE="No Opinion">
<FONT COLOR="#000066"> No Opinion</FONT></FONT><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Did
they answer all your questions?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" name="AnswerQuestions" CHECKED>
Yes
<input type="radio" name="AnswerQuestions" value="No">
No
<INPUT TYPE="radio" NAME="AnswerQuestions" VALUE="No Opinion">
No Opinion</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Did
the consultant seem knowledgeable about the procedures you were inquiring
about?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<input type="radio" value="Yes" name="Knowledgeable" CHECKED>
Yes
<input type="radio" name="Knowledgeable" value="No">
No </FONT><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<INPUT TYPE="radio" NAME="Knowledgeable" VALUE="No Opinion">
<FONT COLOR="#000066"> No Opinion</FONT></FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Did
Dr. Martin spend enough time with you?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" name="TimeSpent" CHECKED>
Yes
<input type="radio" name="TimeSpent" value="No">
No
<INPUT TYPE="radio" NAME="TimeSpent" VALUE="No Opinion">
No Opinion</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">If
not, what time frame would be more appropriate and what needed to be
covered that was not?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<textarea rows="2" name="MoreToCover" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Did
you obtain enough information to make an informed decision?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" name="EnoughInformation" CHECKED>
Yes
<input type="radio" name="EnoughInformation" value="No">
No
<INPUT TYPE="radio" NAME="radiobutton" VALUE="No Opinion">
No Opinion</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Did
you obtain enough information regarding pre-operative instructions and
post-operative care that you felt educated as to what to expect? (given
at pre-operative visit)</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<input type="radio" value="Yes" name="PrePostInstructions" CHECKED>
Yes
<input type="radio" name="PrePostInstructions" value="No">
No </FONT><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<FONT COLOR="#000066">
<INPUT TYPE="radio" NAME="PrePostInstructions" VALUE="No Opinion">
No Opinion</FONT></FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">If
you have looked at our web site, can you tell me what you think of the
presented information and are there any ways to improve it?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<textarea rows="2" name="WebSiteContents" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">If
you have had a consult with another physician, how would you compare
that consult to ours?&nbsp; If something in particular was better than
ours, could you please specify?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<textarea rows="2" name="OtherPhysicianComment" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">If
you have chosen to go to another plastic surgeon, could you tell us
why?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<textarea rows="2" name="WhyOtherPlasticSurgeon" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">If
you have chosen to stay with Dr. Martin, could you tell us why?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<textarea rows="2" name="WhyDrMartin" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">How
was your surgical experience?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<textarea rows="2" name="HowWasSurgery" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Did
your office adequately follow you during the post-operative period?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<input type="radio" value="Yes" name="FollowUps" CHECKED>
Yes
<input type="radio" name="FollowUps" value="No">
No </FONT><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<INPUT TYPE="radio" NAME="FollowUps" VALUE="No Opinion">
<FONT COLOR="#000066"> No Opinion</FONT></FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Regarding
our receptionist - Angie Boileau, did you find her professional and
helpful?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" name="Receptionist" CHECKED>
Yes
<input type="radio" name="Receptionist" value="No">
No
<INPUT TYPE="radio" NAME="Receptionist" VALUE="No Opinion">
No Opinion</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Regarding
our Physician Assistant, Robert Wright&nbsp; PA-C, Did you find him
professional and helpful?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<input type="radio" value="Yes" name="PhysicianAssistant" CHECKED>
Yes
<input type="radio" name="PhysicianAssistant" value="No">
No </FONT><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<FONT COLOR="#000066">
<INPUT TYPE="radio" NAME="PhysicianAssistant" VALUE="No Opinion">
No Opinion</FONT></FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Regarding
our office manager, Sylvia Bennett, did you find her professional and
helpful?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" name="OfficeManager" CHECKED>
Yes
<input type="radio" name="OfficeManager" value="No">
No
<INPUT TYPE="radio" NAME="OfficeManager" VALUE="No Opinion">
No Opinion</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">Regarding
our surgical nurse, Dixie Morrison, did you find her professional and
helpful?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<input type="radio" value="Yes" name="SurgicalNurse" CHECKED>
Yes
<input type="radio" name="SurgicalNurse" value="No">
No </FONT><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<INPUT TYPE="radio" NAME="SurgicalNurse" VALUE="No Opinion">
<FONT COLOR="#000066">No Opinion</FONT></FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left" BGCOLOR="#6666CC"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">Regarding
our medical assistant, Linda Doros, did you find her professional and
helpful?</FONT></td>
<td valign="MIDDLE" align="left" BGCOLOR="#6666CC" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#FFFFFF">
<input type="radio" value="Yes" name="MedicalAssistant" CHECKED>
Yes
<input type="radio" name="MedicalAssistant" value="No">
No
<INPUT TYPE="radio" NAME="MedicalAssistant" VALUE="No Opinion">
No Opinion</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="top" align="left"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">How
could we have made your experience better?</FONT></td>
<td valign="MIDDLE" align="left" COLSPAN="2"><FONT FACE="Verdana, Arial, Helvetica, sans-serif" SIZE="-1" COLOR="#000066">
<textarea rows="2" name="HowCouldWeMakeItBetter" cols="40"></textarea>
</FONT></td>
</tr>
<tr>
<td valign="top" align="left" width="100"></td>
<td valign="MIDDLE" align="CENTER" COLSPAN="3">
<DIV ALIGN="left"></DIV>
<DIV ALIGN="CENTER">
<P><FONT FACE="Verdana, Arial, Helvetica, sans-serif" COLOR="#000066">
<INPUT TYPE="submit" VALUE="Send In These Responses" NAME="SendButton">
<INPUT TYPE="reset" VALUE="Clear These Answers" NAME="ResetButton">
</FONT></P>
</DIV>
</td>
</tr>
</table>
<FONT FACE="Verdana, Arial, Helvetica, sans-serif" COLOR="#000066"> </FONT></div>
<DIV ALIGN="CENTER"></DIV>
</form>
<P>&nbsp;</P>
<P>&nbsp;</P>
</body>
</html>