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Post LASIK Surgery Survey

 

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1. Please Complete the Following:

Please Complete the Following:   First Name
Last Name
Email
Phone
Your Surgeon

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2. What was your

	MM		DD		YYYY
Treatment date?	What was your   Treatment date?   Month	/	Day	/	Year

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3. What was your Treatment

LASIKPRK

What was your Treatment

Other (please specify)

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4. During your Treatment at Eyecare Medical Group:
(please check the box that best matches to your experience)

	Extremely Satisfied	Very Satisfied	Satisfied	Somewhat Dissatisfied	Very Dissatisfied
How would you rate our staff in thoroughly answering questions and preparing you for treatment?	*During your Treatment at Eyecare Medical Group: (please check the box that best matches to your experience) How would you rate our staff in thoroughly answering questions and preparing you for treatment? Extremely Satisfied	How would you rate our staff in thoroughly answering questions and preparing you for treatment? Very Satisfied	How would you rate our staff in thoroughly answering questions and preparing you for treatment? Satisfied	How would you rate our staff in thoroughly answering questions and preparing you for treatment? Somewhat Dissatisfied	How would you rate our staff in thoroughly answering questions and preparing you for treatment? Very Dissatisfied
How would you rate our staff’s explanation of your evaluation and surgery procedure?	How would you rate our staff’s explanation of your evaluation and surgery procedure? Extremely Satisfied	How would you rate our staff’s explanation of your evaluation and surgery procedure? Very Satisfied	How would you rate our staff’s explanation of your evaluation and surgery procedure? Satisfied	How would you rate our staff’s explanation of your evaluation and surgery procedure? Somewhat Dissatisfied	How would you rate our staff’s explanation of your evaluation and surgery procedure? Very Dissatisfied
How would you rate our Refractive Surgery Coordinator’s availability via phone?	How would you rate our Refractive Surgery Coordinator’s availability via phone? Extremely Satisfied	How would you rate our Refractive Surgery Coordinator’s availability via phone? Very Satisfied	How would you rate our Refractive Surgery Coordinator’s availability via phone? Satisfied	How would you rate our Refractive Surgery Coordinator’s availability via phone? Somewhat Dissatisfied	How would you rate our Refractive Surgery Coordinator’s availability via phone? Very Dissatisfied
How would you rate the explanation of your surgery by the physician and his or her staff?	How would you rate the explanation of your surgery by the physician and his or her staff? Extremely Satisfied	How would you rate the explanation of your surgery by the physician and his or her staff? Very Satisfied	How would you rate the explanation of your surgery by the physician and his or her staff? Satisfied	How would you rate the explanation of your surgery by the physician and his or her staff? Somewhat Dissatisfied	How would you rate the explanation of your surgery by the physician and his or her staff? Very Dissatisfied
How would you rate the overall professionalism of the physician?	How would you rate the overall professionalism of the physician? Extremely Satisfied	How would you rate the overall professionalism of the physician? Very Satisfied	How would you rate the overall professionalism of the physician? Satisfied	How would you rate the overall professionalism of the physician? Somewhat Dissatisfied	How would you rate the overall professionalism of the physician? Very Dissatisfied
How would you rate the physician’s ability and willingness to answer your questions?	How would you rate the physician’s ability and willingness to answer your questions? Extremely Satisfied	How would you rate the physician’s ability and willingness to answer your questions? Very Satisfied	How would you rate the physician’s ability and willingness to answer your questions? Satisfied	How would you rate the physician’s ability and willingness to answer your questions? Somewhat Dissatisfied	How would you rate the physician’s ability and willingness to answer your questions? Very Dissatisfied
How would you rate the courteousness of the physician?	How would you rate the courteousness of the physician? Extremely Satisfied	How would you rate the courteousness of the physician? Very Satisfied	How would you rate the courteousness of the physician? Satisfied	How would you rate the courteousness of the physician? Somewhat Dissatisfied	How would you rate the courteousness of the physician? Very Dissatisfied
How would you rate the explanation of instruments to be used during treatment?	How would you rate the explanation of instruments to be used during treatment? Extremely Satisfied	How would you rate the explanation of instruments to be used during treatment? Very Satisfied	How would you rate the explanation of instruments to be used during treatment? Satisfied	How would you rate the explanation of instruments to be used during treatment? Somewhat Dissatisfied	How would you rate the explanation of instruments to be used during treatment? Very Dissatisfied
How would you rate your satisfaction with answers given to you regarding your treatment?	How would you rate your satisfaction with answers given to you regarding your treatment? Extremely Satisfied	How would you rate your satisfaction with answers given to you regarding your treatment? Very Satisfied	How would you rate your satisfaction with answers given to you regarding your treatment? Satisfied	How would you rate your satisfaction with answers given to you regarding your treatment? Somewhat Dissatisfied	How would you rate your satisfaction with answers given to you regarding your treatment? Very Dissatisfied
How would you rate the instructions given to you for follow-up care (i.e. use of medications, eye drops, activity limitations, etc.)?	How would you rate the instructions given to you for follow-up care (i.e. use of medications, eye drops, activity limitations, etc.)? Extremely Satisfied	How would you rate the instructions given to you for follow-up care (i.e. use of medications, eye drops, activity limitations, etc.)? Very Satisfied	How would you rate the instructions given to you for follow-up care (i.e. use of medications, eye drops, activity limitations, etc.)? Satisfied	How would you rate the instructions given to you for follow-up care (i.e. use of medications, eye drops, activity limitations, etc.)? Somewhat Dissatisfied	How would you rate the instructions given to you for follow-up care (i.e. use of medications, eye drops, activity limitations, etc.)? Very Dissatisfied

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5. Please rate the following:

	Yes	No	Unsure
Did you receive a follow up call from our clinical staff after treatment?	*Please rate the following: Did you receive a follow up call from our clinical staff after treatment? Yes	Did you receive a follow up call from our clinical staff after treatment? No	Did you receive a follow up call from our clinical staff after treatment? Unsure
Was your overall experience with our practice exemplary enough so that you would consider referring your friends or relatives for consultation?	Was your overall experience with our practice exemplary enough so that you would consider referring your friends or relatives for consultation? Yes	Was your overall experience with our practice exemplary enough so that you would consider referring your friends or relatives for consultation? No	Was your overall experience with our practice exemplary enough so that you would consider referring your friends or relatives for consultation? Unsure

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6. If your experience with our practice was less than satisfactory, would you like to be contacted to discuss how we can improve?

YesNo

If your experience with our practice was less than satisfactory, would you like to be contacted to discuss how we can improve?

Suggestions?