Home
About
About Dr. Alpern
Our Practice
Our Team
Vision and Mission
Testimonials
Vein Disorders
Venous System
Venous Disease
Signs and Symptoms
Spider Veins
Varicose Veins
Chronic Venous Insufficiency
Venous Leg Ulcers
Vein Treatment
Venous Disease Diagnosis
Venous Disease Treatment
Gallery
Image Gallery
Video Gallery
FAQ’s
Patient Center
Patient Forms
Pay My Bill
Patient Satisfaction Survey
Blog
Newsletters
Contact
English
Español
Patient Satisfaction Survey
Your valuable input helps us to serve you in the best possible way. This survey for our patients helps us to determine your level of satisfaction, what we are doing well and where we can improve our services to you.
Step 1 of 5
20%
Choose your best answers to the following questions related to your vein treatment services:
Front Desk
Courtesy and professionalism of our front desk personnel:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Efficiency of our patient intake process:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Clarity of instructions prior to procedure:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Explanation of our billing procedure with your insurance company:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Explanation of your payment responsibilities:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Office Appointments
Courtesy and professionalism of our ultrasound technician(s):
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Courtesy and professionalism of our surgical staff:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Communication between staff and family member:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Actual waiting times as compared with anticipated waiting times indicated by our staff:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Facility
Was our waiting room comfortable:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Was our surgical suite comfortable:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Treatment Details
Name:
*
First
Last
Phone:
*
Email:
*
Enter Email
Confirm Email
Address Details:
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Physician / Provider:
Specify type(s) of vein treatment received (check all that apply):
*
Spider Veins
Varicose Veins
Leg Ulcer
Chronic Venous Insufficiency
Venous Disease
Cosmetic Vein Treatment
Last Date of Treatment
*
MM
DD
YYYY
Additional Information
Would you recommend VSA to your family and friends:
*
Definitely
Probably
Not Sure
Probably Not
Definitely Not
Additional Comments:
VSA Privacy Policy