The Vein & Laser Center of New England

Initial Consult Questionnaire

This questionnaire is completely anonymous. If you have the time, please provide more information in the detail box provided

1. How did you first hear about us?
Physician Referral Newspaper ad Radio ad Former Patient	Friend Web search Other

2. Were you able to make initial contact with our office without difficulties? Yes No Details:
3. How were you treated over the phone when you first made contact?
Very well As expected "Ok" Poorly	Details:

4. Were you satisfied with the scheduled appointment? Yes No, too long a wait No, could not accommodate my schedule
5. When you arrived at the Center were your expectations fulfilled in regards to the physical environment and how you were treated by the staff? Yes No Details:
6. Did your Initial Consultation meet expectations: Yes No Details:
7. Were you satisfied with by Dr. Roupenian’s demeanor and how you were treated during the Consultation? Yes No Details:
8. Did you feel the teaching by Dr. Roupenian during the Consultation met your expectations?
Yes No, too detailed No, too confusing	Details:

9. Did you have any concerns regarding recommended treatments that you did not express at the time of the initial visit. If yes please provide the details:
10. If the procedure recommended was self-pay did you feel that the cost was reasonable? Yes No Details:
11. Would you recommend the Vein & Laser Center of New England to others? Yes No Details:
12. Please take a moment to express any recommendations that you feel would make the Vein & Laser Center a better experience.
This is a non-secure means of communication!

Post Procedure Questionnaire

This questionnaire is completely anonymous. If you have the time, please provide more information in the detail box provided

1. Which procedure did you undergo at the Center?
Endovenous laser Endovenous RF Laser with phlebectomy RF with phlebectomy Phlebectomy alone	Injection sclerotherapy Foam sclerotherapy Surface laser treatment Other

2. Do you feel you were properly prepared by Dr. Roupenian and his staff for the procedure? Yes No Details:
3. Were you satisfied with the physical environment during your procedure? Yes No Details:
4. Did the demeanor of the staff and the way you were treated during the procedure meet your expectations? Yes No Details:
5. How much pain if any did you experience? None Minimal Moderate Severe
6. Would you have the procedure again or recommend it to family or friends? Yes No Details:
7. Were you properly prepared by Dr. Roupenian and his staff on what to expect after the procedure? Yes No Details:
8. How much discomfort did you feel during the week following the procedure? None Minimal Moderate Severe
9. Were you properly prepared by the staff for the degree of discomfort you did experience? Yes No
10. Are you satisfied with the outcome of your procedure? Yes No Details:
11. Is there anything you would recommend be done by Dr. Roupenian and the staff of the Center to improve on the quality of your experience? Details:
This is a non-secure means of communication!

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Vascular Surgeon Dr Armen L Roupenian offers treatment for Varicose and Spider Veins by using Foam Sclerotherapy, Endovenous, and other procedures.
Serving Plymouth, Pembroke, Marshfield, Middleboro, Norwell, Sandwich, Taunton, Wareham, Kingston, Duxbury, and the surrounding areas.

The Vein and Laser Center of New England | 45 Resnik Rd. | Ste. 305 | Plymouth, MA 02360 | 508-747-1333 | www.veins-away.com

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