Cosmetic Interest Questionnaire (CIQ) app Survey
Thank you for completing this brief questionnaire. Upon its completion, we will arrange a convenient time for a phone call to further customize the Cosmetic Interest Questionnaire iPad app for your Practice.

Your customized app will be available within 24 hours of completion of this form. We promise that this CIQ app is SIMPLE and POWERFUL and are happy we are now able to share it with you.

You may download the app now and begin to use it at no cost for a trial period to make sure it suits your needs
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We want to remind you that ALL of this information is strictly confidential and will NOT be shared with ANYONE.

Thank you.

Jon Mendelsohn, MD, FACS
Medical Director

Practice Info
Physician(s) Name(s) *
Your answer
Best Contact Name *
Your answer
Best Contact Phone *
Your answer
Practice Website *
(if you have one, if you do not simply reply "NA")
Your answer
How many employees (FTE) do you have? *
FTE = full time equivalents
How many Doctor's are in the Practice? *
This includes all Doctor's regardless of number of hours they work each week.
How many other Providers deliver cosmetic services within the Practice? *
Include Nurse Practitioners, Physician Assistants, Aestheticians etc.
What is/are the Specialty(s) of the Practice? *
Are you trying to add services to the Practice? if so, explain.
Your answer
Marketing Info
Do you currently use any Cosmetic Interest Questionnaire (CIQ) Form? *
If you answered "YES" above, what is your experience with the CIQ?
Has it been successful? Does it work? Does your team follow through? What is the best part of using it? What is difficult about using it? etc.
Your answer
What is Practice Marketing Expense ratio, as a percentage of revenue?
ie. for 1M in revenue a 5% Marketing Expense would be 50k
Do you use any form of e-mail marketing? *
Do you use any patient satisfaction surveys? *
Do you currently have business partnerships with any of the following? *
ie regularly refer to spas, salons, cosmetic dentists, dermatologists etc. (Check all that apply)
What EMR software do you use if any? *
Please list any other "software" solutions that you currently use or would like to use in the future.
Your answer
Do you work with one of Allergan's APC's (Consultants)?
if so, who?
Your answer
Please check ALL of the areas that you may want on your CIQ iPad app. *
Try it immediately (within 24 hours). We will email you when your app has been customized for your Practice. There is NO FEE. Use it for 1 month - Complimentary. This is 100% customizable - so don't think too much, it just a place to get started.
Please provide any other questions or information that you feel would be helpful prior to our online meeting.
Your answer
Cosmetic Interest Questionnaire iPad App - Free Download
                      Download from the iTunes App Store
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This form was created inside of Advanced Cosmetic Surgery & Laser Center.