Skip to main content
Menu
Home
About
About Us
Meet Dr. Payne
Online Reviews
Multi-Specialty Team
What is Craniofacial Plastic Surgery?
Technology
Philanthropy
Conditions & Treatments
Craniofacial Syndromes
Crouzon Syndrome
Pfeiffer Syndrome
Saethre Chotzen Syndrome
Treacher Collins & Nager Syndrome
Hemifacial Microsomia Goldenhar Syndrome
Maxillonasal Dysplasia – Binder Syndrome
Lip and Palate Birth Defects
Cleft Lip & Cleft Palate Deformity
Adult Cleft Lip and Palate
Pierre Robin Sequence
Velocardiofacial Syndrome
Velopharyngeal Insufficiency
Craniosynostosis
Sagittal Craniosynostosis
Metopic Craniosynostosis
Coronal Craniosynostosis
Lambdoid Craniosynostosis
Other Skull Deformities
Orbital Hypertelorism
Frontonasal Dysplasia
Facial Clefts
Encephalocele
Orthognathic (Jaw) Surgery
Chin Augmentation
Sleep Apnea
Nasal and Facial Reconstruction Surgery
Rhinoplasty
Revision Rhinoplasty (Nasal Reconstruction)
Mohs Reconstruction
Facial Trauma Reconstruction
Distraction Osteogenesis
Ear Deformities
Infant Ear Molding and the EarWell
™
Otoplasty (Ear Surgery)
Microtia
Earlobe Repair
Vascular Malformations
Capillary Malformations
Hemangioma
Venous Malformations
Arteriovenous Malformations (AVM)
Plagiocephaly
Skin Lesions
Congenital Nevus
Other Conditions and Treatments
Polydactyly and Syndactyly
Gallery
Blog
Resources
Infant Ear Molding
Texas Liposuction Specialty Clinic
Contact
713-461-8866
Resources
Home
/
Resources
Please fill Out Our Helpful Patient Survey
Name
(Required)
First
(Please write anonymous if you do not wish to disclose your name)
Date of Visit
MM slash DD slash YYYY
How satisfied are you in regards to your appointment ?
Ease of making an appointment
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Appointment available within a reasonable amount of time
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Efficiency of the check-in process
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Waiting time in reception area
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Keeping you informed if your appointment time was delayed
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Waiting time in exam room
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
How satisfied are you with the following in regards to our staff?
Friendliness and courtesy of the receptionist
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Caring concern of our nurses/medical assistants
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Helpfulness of the people who assisted you with billing or insurance
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Overall professionalism of staff
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
How satisfied are you with our communication with you?
Your phone calls answered promptly
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Our ability to return your calls in a timely manner
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Your ability to contact us after hours
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Explanation of your procedure
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
How satisfied are you with your visit with Dr. Payne?
Willingness to listen carefully to you
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Taking time to answer your questions
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Explaining things in a way you could understand
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Instructions regarding medication/follow up care
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
N/A
Please rate our facility:
Overall comfort
Select an Option
5
4
3
2
1
Hours of operation convenient for you
Select an Option
5
4
3
2
1
Cleaniness of waiting room
Select an Option
5
4
3
2
1
Cleaniness of exam room
Select an Option
5
4
3
2
1
Adequate parking
Select an Option
5
4
3
2
1
Were your financial options explained?
yes
no
Are signage and directions easy to follow?
yes
no
Is our location convenient for you?
yes
no
Would you refer your friend or family to us?
yes
no
Do you have any additional comments/suggestions?