Satisfaction Survey

Your Doctor... *

Communication prior to appointment *

Appointment availability *

Waiting room time *

Fees *

Quality of care from staff *

Quality of care from doctor *

Concerns or questions answered *

Overall quality of care *

Preferred day for appointments *

Preferred time for appointments *

Do you plan on returning for your next comprehensive examination? *

Yes No

Please tell us why not.

Would you schedule appointments onine? *

Yes No

Satisfaction with eyeglasses *

Satisfaction with contact lenses *

Range of eyeglasses selection *

What helped you make your decision on where to purchase your eyewear?

This survey can be anonymous but, if you would like to include your name, you will receive a $10 gift certificate to use at our clinic.

Why did you choose us for your eye health care?

Name First Last

Additional comments

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