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Practice Evaluation

Contact Information

Name
Practice Name
Address
City/State/Zip
Phone Fax
Email
Web Address

Specialty
Contact Person
Best Time To Contact?

About You

You Currently Practice: On Your Own In A Group
You Have Location(s)
Please Check The Cosmetic Procedures You Currently Offer: <CTRL> click to select more than one	Other
Please Check The Cosmetic Procedures You Are Considering Adding <CTRL> click to select more than one	Other
You Would Like To Add The Above Services Within
The Above Cosmetic Services Will Be Added	To My Current Practice To A Stand Alone Clinic
Do You Have A Business Plan To Achieve This Growth?	Yes No
How Many Patients Do You See Per Day?
Of Those Whom You See, What Percentage Of Patients Inquire About Anti-aging Products?
How Many Laser Cosmetic Patients Do You See In An Average Month?
What Are The Most Popular Treatments Performed In Your Office?
How Many Years Have You Been In Practice In Your Area?
Indicate If You Have Had The Following Prepared: <CTRL> click to select more than one
How Many Cosmetic Consultations Are Given In Your Office Per Week?
Revenue From Your Cosmetic Services Are Tracked
Do You Track Information Calls Verses The Number Of Consultations Scheduled?	Yes No
Do You Track Consultations Versus The Number Of Treatments Scheduled?	Yes No
How Are You Currently Tracking The Above Data?
You Charge $ For A Cosmetic Consultation.
Do You Update Existing Patients Regularly On The Different Services You Offer?	Yes No
Do You Have An Aesthetician On Staff?	Yes No
Do You Have A Patient Coordinator?	Yes No
Do You Have The Staff To Support Future Growth?	Yes No

Advertising/Marketing

Your Current Advertising Consists Of: <CTRL> click to select more than one	Other
You See Your Advertising Success As
Do You Track The Effectiveness Of Your Advertising Dollars?	Yes No
The Average Age Of Your Cosmetic Patient Is
Rate Your Practice In Comparison With Your Competitor
Do You Have Internet Access In Your Office?	Yes No
Does Your Practice Have It's Own Web Site?	Yes No
If No, Does Your Practice Have Plans For Developing A Web Site In The Next 12 Months?	Yes No
What Is Your Monthly Advertising Budget?

What Percentage Of This Budget Is Spent On.....
Newspaper Radio Television
Magazine Newsletter Other

Staff Training

Rate Your Staff's Knowledge Of Your Cosmetic Services
What Staff Turnover Are You Currently Experiencing?
How Often Do You Hold A Formal Staff Meeting?
Rate From 1 To 10 (10 Being Perfect) How You Feel New Patients Perceive The Staff.

What Type(s) Of Training Do You Provide In Your Practice

Indicate The Number Of Staff Currently Associated With Your Practice
Front Office Back Office RN/PA's Physicians

Future/Growth

You Plan To Increase Monthly Revenues Over The Next Six Months By
Do You Have A Clear Growth Plan?	Yes No
Does Your Geographic Location Pose A Problem For Growth?	Yes No

Indicate The Number Of Staff You Have Budgeted For Expansion
Front Office Back Office RN/PA's Physicians

Comments

A bout Your Practice (Competition, Challenges) That You Would Like To Share.

If You Could Change Anything About Your Practice It Would Be

Staff Training

Marketing & Advertising

Marketing Packages

Success Stories

Practice Evaluation

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