Satisfaction Survey

We would be happy to get back to via phone or email if you have concerns that require a follow-up. If so, please do not forgot to include your contact information in the last field below.

Please complete the following form:



Doctor:


Service Ratings

Communication prior to appointment:  Great Good Fair Poor N/A
Appointment availability:  Great Good Fair Poor N/A
Waiting room time:  Great Good Fair Poor N/A
Fees:  Great Good Fair Poor N/A
Quality of care from staff:  Great Good Fair Poor N/A
Quality of care from doctor:  Great Good Fair Poor N/A
Concerns or questions answered:  Great Good Fair Poor N/A
Overall quality of care:  Great Good Fair Poor N/A

Scheduling

Preferred day for appointments:

Preferred time for appointments:

Do you plan on returning for your next comprehensive examination?  Yes No
For No, please tell us why not:
Would you like to schedule your appointments on-line?  Yes No

Products

Satisfaction with eyeglasses:  Great Good Fair Poor N/A
Satisfaction with contact lenses:  Great Good Fair Poor N/A
Range of eyeglasses selection:


Identification

Why did you choose us for your eye health care?

Your Name

Additional comments