My Family Focus Experience Survey

1. Telephone Contact

	Poor	Fair	Good	Excellent	N/A
Telephone contact with staff was friendly and informative	Telephone Contact Telephone contact with staff was friendly and informative Poor	Telephone contact with staff was friendly and informative Fair	Telephone contact with staff was friendly and informative Good	Telephone contact with staff was friendly and informative Excellent	Telephone contact with staff was friendly and informative N/A

Other (please specify)

2. Examination

	Poor	Fair	Good	Excellent	N/A
Thorough explanation of testing and your personal results	Examination Thorough explanation of testing and your personal results Poor	Thorough explanation of testing and your personal results Fair	Thorough explanation of testing and your personal results Good	Thorough explanation of testing and your personal results Excellent	Thorough explanation of testing and your personal results N/A

Other (please specify)

3. My questions

	Poor	Fair	Good	Excellent	N/A
Time taken to answer your questions in all areas of the clinic	My questions Time taken to answer your questions in all areas of the clinic Poor	Time taken to answer your questions in all areas of the clinic Fair	Time taken to answer your questions in all areas of the clinic Good	Time taken to answer your questions in all areas of the clinic Excellent	Time taken to answer your questions in all areas of the clinic N/A

Other (please specify)

4. Delivery of eyewear

	Poor	Fair		Excellent	N/A
Received glasses/contacts within the time you were told to expect them	Delivery of eyewear Received glasses/contacts within the time you were told to expect them Poor	Received glasses/contacts within the time you were told to expect them Fair	Received glasses/contacts within the time you were told to expect them	Received glasses/contacts within the time you were told to expect them Excellent	Received glasses/contacts within the time you were told to expect them N/A

Other (please specify)

5. Satisfaction

	Poor	Fair	Good	Excellent	N/A
Possibility that you will return and/or refer others to our care	Satisfaction Possibility that you will return and/or refer others to our care Poor	Possibility that you will return and/or refer others to our care Fair	Possibility that you will return and/or refer others to our care Good	Possibility that you will return and/or refer others to our care Excellent	Possibility that you will return and/or refer others to our care N/A

Other (please specify)

6. Please let us know if you are aware of these clinic services

	Yes	No
Free 2-year frame and lens warranty	Please let us know if you are aware of these clinic services Free 2-year frame and lens warranty Yes	Free 2-year frame and lens warranty No
Share the Care $20 credit for referrals	Share the Care $20 credit for referrals Yes	Share the Care $20 credit for referrals No
Free eyewear tune ups and pad replacement	Free eyewear tune ups and pad replacement Yes	Free eyewear tune ups and pad replacement No
Scheduling up to 2 years in advance for your convenience	Scheduling up to 2 years in advance for your convenience Yes	Scheduling up to 2 years in advance for your convenience No
Free consultations to discuss Lasik vision correction	Free consultations to discuss Lasik vision correction Yes	Free consultations to discuss Lasik vision correction No

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Dr. Vorpahl and all of his staff thank you for helping us to better understand the needs of our patients--the most important people in our clinic!

My Family Focus Experience
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