Satisfaction Survey

Please let us know how your last visit went.

Service Ratings

Rate each of the following from Great to Poor, or N/A if not applicable.

Category	Great	Good	Fair	Poor	N/A
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

Would you schedule appointments online?

Yes No

Product	Great	Good	Fair	Poor	N/A
Satisfaction with eyeglasses
Satisfaction with contact lenses

Range of eyeglasses selection

Why did you choose us for your eye health care?

Your Name (Optional)

Additional comments