| Was our staff courteous and
helpful? |
Yes No |
| Were you seen in a timely
manner? |
Yes No |
| Was your examination
thorough? |
Yes No |
| Were you satisfied with the
explanation of your visual conditions and treatment options |
Yes No |
| If fit with contact lenses
or glasses, did the service and quality meet your
expectations? |
Yes No |
| Would you refer a friend to
our office for eye care? |
Yes No |
| Why?
_______________________________________________________________ |
|
| How would you rate your
overall satisfaction with our office? (10=excellent; 1=poor) |
______ |
| What was the most memorable
thing that happened at our office? |
|
_____________________________________________________________________
_____________________________________________________________________ |
|
| Other comments: |
|
_____________________________________________________________________
_____________________________________________________________________ |
|
Name (optional)
____________________________________
Date___________
THANK YOU FOR YOUR ASSISTANCE |
|