Review

Patient Survey

Please select a number from 1-5 (1 - Unacceptable, 2 - Needs improvement, 3 - Meets expectations, 4 - Exceeds expectations, 5 - Outstanding):

Overall rating (How would you rate your overall experience with us?)

	1	2	3	4	5

Recommend to a friend (Would you trust us to make recommendations that are in your best interest?)

	1	2	3	4	5

Level of trust (Would you trust us to make recommendations that are in your best interest?)

	1	2	3	4	5

Office staff (Friendliness and courtesy of the office staff)

	1	2	3	4	5

Office environment (Cleanliness, comfort, lighting, temperature, location)

	1	2	3	4	5

Helpfulness (Did we help you understand your medical condition/ conditions?)

	1	2	3	4	5

Wait time (Time you waited in the waiting room? 1 would be “too long” and 5 would be “great wait time”)

	1	2	3	4	5

Scheduling time (Time you waited to get an appointment after requesting one)

	1	2	3	4	5

Comments (Please share your experience with us)

I agree to allow Center for Vein Wellness, Center for Advanced Wound Care, Luxe Aesthetic Surgery & Medical Spa, Center for Advanced Hair Restoration, S-Sculpt Cosmetic & Medical Institute, Dr Shah and their marketing team to use the survey and testimonial on websites owned by these practices. If needed, I will also allow a user profile to be created on my behalf in order to submit my review to trusted medical review websites (such as but not limited to Google, Vitals.com, and Healthgrades.com). I will allow my name (first name and last name’s initial (not full name)) to be used solely for the purpose of submitting this review online on such websites. This survey WILL NOT be shared with other companies or websites other than for the sole purposes of online reviews.*

Agree*

Patient Name

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Affordable Financing Options

Make your aesthetic goals more accessible with flexible financing options at LUXE. Convenient monthly payment plans can help you move forward with surgical procedures, injectables, skin rejuvenation, and other treatments without paying the full cost upfront. Ask our team about available financing options during your consultation.