Godfrey & Godfrey

We are very much interested in learning more about the needs of people seeking an understanding of cosmetic surgery. Your answers to our survey will assist us in our efforts to improve the services we provide to the community.

In return for your thoughtful completion of our form, Drs. Godfrey are pleased to offer a half-priced initial visit at which you may begin to learn about the cosmetic surgery in which you have interest. (Note: Your real name and email are required in order to be credited a discount.)

Please fill out this form completely before submitting.

1.	First Name:
2.	Last Name:
3.	EMail:
4.	Street:
5.	City:
6.	State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New JersUserey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7.	Zip:
8.	Age:
9.	Sex:		Choose One Male Female
10.	Interest:		Choose... Abdominoplasty Breast Augmentation Breast Lift Breast Reduction Chin Augmentation Ear Surgery Eyelidplasty Facelift Laser Resurfacing Lip Augmentation Liposuction Male Breast Reduction Rhinoplasty Scar Revision
11.	Other Interest: (if not shown above)
12.	What is your main information source on cosmetic surgery?		Choose... Ads Friend Library Magazines Prior Surgery Internet Private MD Television
13.	What is of primary concern to you in choosing a cosmetic surgeon?		Choose One Credentials Hospital Affiliation Office Location Price of Surgery Recommendation of Friend Recommendation of my Physician Surgeon Demeanor Surgeon Experience
14.	When you consult a surgeon you are...		Choose One Looking for information Looking for advice Planning to schedule surgery Shopping for doctor
15.	Have you had cosmetic surgery before?		Choose One Yes No
16.	Have friends or relatives had cosmetic surgery?		Choose One Yes No
17.	If you choose surgery, where would you prefer it be performed?		Choose One Office Hospital
18.	What best describes your reason for seeking cosmetic surgery?		Choose One To compliment your fitness program To feel better about yourself To help you in your profession To please another To remove a "deformity" Other
19.	How did you find this web site?		Choose... Got address from literature Google Yahoo MSN AOL Other Search Engine Found in Magazine Link in other site Told by friend Other
20.	Have you found this site...		Choose One Very helpful Somewhat helpful Not helpful
21.	What changes in the site would you find helpful?		No changes
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Cosmetic Surgery New York   *  Manhattan  *  Queens
New York Plastic Surgeon: Philip Godfrey MD
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