Customer Satisfaction Survey

Please let us know how your last visit went.

Location

Doctor

Service Ratings

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?

Please tell us why not

Would you schedule appointments online?

Please tell us why not

Satisfaction with eyeglasses

Satisfaction with contact lenses

Range of eyeglasses selection

Why did you choose us for your eye health care?

Your Name (Optional)

First Last

Additional comments

Phone

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