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Ted Rothstein DDS, PhD
Specialist in Orthodontics Adults and Children
[Www.Drted.Com]
Mission Statement: "Our
priority is caring for you and our mission is quality care."
Dear ______________:
Thank you for having come to my office for your orthodontic consultation-examination some time ago. Your name was brought to my attention recently when , the treatment coordinator, reviewed your case with me and informed me that you have chosen not to go ahead with your treatment at our office.
Of course not all patients who I examine choose me, or even require treatment, as they soon learn from the detailed report that I provide them with at the conclusion of my examination.
I have taken the liberty of enclosing that report along with a stamped, pre-addressed envelope, a questionnaire and a gift certificate for the amount of $______ in the hope that you will be kind enough to complete the questionnaire and return it to me.
It is the principal method I use to help understand and improve the office so that the needs of my future would-be patients are best served. I would be grateful if you can take some time to fill out the form below. Please be frank and honest.
Thanking you in advance for your time. Your response will help us achieve our patient-care mission.
Cordially, Dr. Ted Rothstein www.drted.com
The reasons/issues that best explain why you did not choose my office for providing the orthodontic treatment you were considering:
Please check off 1, 2 or 3 only if the issue had a degree of importance in your
considerations.
if the issue was very important to you circle the 1
if the issue was important to you circle the 2
if the issue had some importance to you circle the 3
FEE ISSUES:
The fee quoted was excessive for you. 1 2 3
If the fee was lower you would have chosen the office. 1 2 3
Your office would not accept my insurance as total payment for the treatment. 1 2 3
The out-of-pocket fee was too much for me to afford. 1 2 3
The payment plans that were presented could not meet my needs. 1 2 3
THE OFFICE:
You did not like the atmosphere/ambience of the office. 1 2 3
The rest rooms were not clean enough. 1 2 3
You saw something in the office that made you think that the office was not sufficiently clean/sterile. 1 2 3
PATIENT-RELATED ISSUES:
You were not psychologically ready to begin. 1 2 3
You had heard that waiting for all the adult teeth to erupt was the best time to begin treatment and you did not want to start before that. 1 2 3
You had already seen an orthodontist, and had more or less chosen that orthodontist. You needed a second opinion just to be sure. 1 2 3
You did not wish to have teeth removed to accomplish your goals. 1 2 3
It bothered you that Dr. Ted thought your problem was not significant enough to warrant treatment. 1 2 3
Dr. Ted did not provide you with sufficient reason so that you could see the value of having your teeth corrected. 1 2 3
It bothered you that Dr. Ted could not simply treat only your chief complaint, but that it was necessary to provide you with some comprehensive orthodontic treatment (braces on all your teeth) that you felt you did not want or need. 1 2 3
You wanted Invisalign only (no braces or wires, removable and invisible) and Dr. Ted explained that Invisalign was not a sufficient treatment remedy for your case. 1 2 3
You felt the Dr. Ted's doctors examination was poorly done, not complete or thorough enough, or too rapid. 1 2 3
You were unhappy/disappointed that Dr. Ted provided you with a diagnosis and treatment plan without first having your molds and x-rays to look at. 1 2 3
The doctor did not speak simply. He used words that you could not understand and you felt confused, overburdened or bewildered. 1 2 3
Dr. Ted did not offer/show/demonstrate/ options regarding the specifics of your treatment... i.e. slenderizing teeth as an option to removal of teeth. 1 2 3
Dr. Ted did not suggest any possible treatment compromises that might have made you choose him to be your orthodontist. 1 2 3
You did not feel that you had a good rapport with Dr. Ted. 1 2 3
You had another consultation and found a doctor with whom you felt you "connected" with better. 1 2 3
Dr. Ted's office could not provide with the patient-care office hours you needed. 1 2 3
LOCATION:
You need an office more conveniently located. 1 2 3
You felt the office was not located in a nice/safe neighborhood. 1 2 3
MISCELLANEOUS:
After (or before) seeing Dr. Ted, a friend who had/did not have treatment recommended another orthodontist and you decided to go to that other orthodontist. 1 2 3
Dr. Ted was unpleasant/rude. 1 2 3
Dr. Ted's appearance was unpleasing to you. 1 2 3
You were kept waiting an excessive amount of time. 1 2 3
You felt that the STAFF was unpleasant/rude/ not helpful enough. 1 2 3
No specific reason you just got cold feet. 1 2 3
Answer YES or NO to the following questions:
You would like the office to discard your file. Y N
You would like to be contacted 6 months from now. Y N
You would like us to contact you now. Y N
I CORDIALLY INVITE YOU TO ADD OTHER POSSIBLE REASONS OR SHARE YOUR COMMENTS WITH ME:
www.drted.com 718 852 1551
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