Hair Transplant Mentor Clinic Interview Form

- Operational and Logistics Questions -

1. How long have you been performing hair restoration surgery?

0 to 3 years ______
4 to 7 years ______
8 to 11 years ______
12 to 15 years ______
Longer ______

2. How many hair transplant surgeries have you performed?

0 to 500 ______
500 to 2500 ______
2500 to 5000 ______
5000 to 7500 ______
7500 to 10000 ______
More ______

3. How many surgeries do you perform in one day?

One ______
Two ______
Three ______
More ______

4. Do you perform surgeries other than hair restoration? ______________ (Y/N)

5. How much involvement can I expect from the doctor in my surgery?

100% ______
75% ______
50% ______
25% ______

6. How much involvement can I expect from technicians in my surgery?

100% ______
75% ______
50% ______
25% ______
7. How long has the newest technician been working at the clinic? ___________

8. Do you wear a surgical mask at all times during the procedure? ____________(Y/N)

9. Do techs wear surgical masks at all times during a procedure? _____________(Y/N)

10. What measures have you taken to prevent post-surgical infection? _______________

_______________________________________________________________________

11. Have you taken measures to prevent the presence of MRSA, CRKP, VRE or other
known hospital derived “super bugs”? _________________(Y/N)

12. Have any of your patients had infection post-surgery? __________________(Y/N)

13. (If the consultation is in the clinic) May I have a tour of the facility? _________
(Y/N)

13a. If no, why? _________________________________________

14. Can I speak with former patients? ______ (Y/N)

First name _______________

Phone # __________________
Email _____________________

First name _______________

Phone # __________________
Email _____________________

First name _______________

Phone # __________________
Email _____________________

First name _______________

Phone # __________________
Email _____________________

If no, why?

_______________________________________________________________________
16. What is the deposit policy?

______________________________________________________________

17. What is the cancellation policy?

_________________________________________________________

18. What is your satisfaction policy?

________________________________________________________

19. How often will I hear from your clinic the first year after my surgery?

Between 1 and 3 times ______

Between 3 and 6 times ______
Between 6 and 9 times ______
Between 9 and 12 times ______

20. What is your satisfaction rate?

Between 70% and 80% ______

Between 80% and 90% ______
Between 90% and 100% ______

21. What is the solution for patients that have not been satisfied with their results?

Refund ______
More surgery ______
Combination ______

22. If I am not satisfied will I have my choice of options? _______________(Y/N)

23. How many of your patients have been unsatisfied in the past calendar year?__________

24. Aside from the cost of surgery, what other fees are involved?

Medication costs ______

Surgical Room Fee ______
Accommodations ______
Medications ______

25. Is the price quoted the price I will pay or is this subject to change? __________(Y/N)

Doctor/Consultant Initials
______________________
 Additional Notes

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