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state-of-the-art treatment & cure for venous disease
skin treatments for restoring your natural, youthful beauty
permanent hair removal
 
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Please select one answer to each of the questions below regarding your experience at JVAI.
Scale Definition 1- Excellent 2- Very Good 3- Average 4- Fair 5- Poor 6- NA
   
FRONT DESK
1. Courtesy and professionalism of our front desk personnel?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
2. Efficiency of our patient intake process?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
3. Clarity of instructions prior to procedure?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
4. Explanation of our billing procedure with your insurance company?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
5. Explanation of your payment responsibilities?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
 
OFFICE APPOINTMENTS
6. Courtesy and professionalism of our ultrasound technician(s)?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
7. Courtesy and professionalism of our aesthetic technician(s)?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
8. Courtesy and professionalism of our surgical staff?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
9. Communication between staff and family member?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
10. Actual waiting times as compared with anticipated waiting times indicated by our staff?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
 
FACILITY
11. Was our waiting room comfortable?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
12. Was our aesthetic suite comfortable?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
13. Was our surgical suite comfortable?
1. Excellent
2. Very Good
3. Average
4. Fair
5. Poor
6. NA
   
COMMENTS:
   
  HOW COULD WE HAVE IMPROVED OUR SERVICE TO YOU?
 
   
14. Would you utilize a Punta Gorda location?
Yes
No
15. Would you recommend JVAI to your family and friends?
Yes
No
   
PATIENT INFORMATION
First Name:
Last Name:
Telephone:
Alternate Phone:
Procedure:
Physician:
Date of Service:
   
 
 
 
25092 Olympia Avenue • Punta Gorda, FL 33950
Phone: (941) 575-0123
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