Survey

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Thank you for taking the time to fill out our Patient Satisfaction Survey. We hope to improve our services based on your responses.

Please rate the following:

	Excellent	Very Good	Good	Fair	Poor	N/A
1. Promptness by which you were seen by the doctor	Please rate the following: 1. Promptness by which you were seen by the doctor Excellent	1. Promptness by which you were seen by the doctor Very Good	1. Promptness by which you were seen by the doctor Good	1. Promptness by which you were seen by the doctor Fair	1. Promptness by which you were seen by the doctor Poor	1. Promptness by which you were seen by the doctor N/A
2. Thoroughness of care you recieved	2. Thoroughness of care you recieved Excellent	2. Thoroughness of care you recieved Very Good	2. Thoroughness of care you recieved Good	2. Thoroughness of care you recieved Fair	2. Thoroughness of care you recieved Poor	2. Thoroughness of care you recieved N/A
3. Clarity of Doctor's explanations	3. Clarity of Doctor's explanations Excellent	3. Clarity of Doctor's explanations Very Good	3. Clarity of Doctor's explanations Good	3. Clarity of Doctor's explanations Fair	3. Clarity of Doctor's explanations Poor	3. Clarity of Doctor's explanations N/A
4. Doctor's friendliness and courtesy	4. Doctor's friendliness and courtesy Excellent	4. Doctor's friendliness and courtesy Very Good	4. Doctor's friendliness and courtesy Good	4. Doctor's friendliness and courtesy Fair	4. Doctor's friendliness and courtesy Poor	4. Doctor's friendliness and courtesy N/A
5. Staff's friendliness and courtesy	5. Staff's friendliness and courtesy Excellent	5. Staff's friendliness and courtesy Very Good	5. Staff's friendliness and courtesy Good	5. Staff's friendliness and courtesy Fair	5. Staff's friendliness and courtesy Poor	5. Staff's friendliness and courtesy N/A
6. Help with understanding your insurance coverage (if applicable)	6. Help with understanding your insurance coverage (if applicable) Excellent	6. Help with understanding your insurance coverage (if applicable) Very Good	6. Help with understanding your insurance coverage (if applicable) Good	6. Help with understanding your insurance coverage (if applicable) Fair	6. Help with understanding your insurance coverage (if applicable) Poor	6. Help with understanding your insurance coverage (if applicable) N/A
7. Variety of eyeglass frames	7. Variety of eyeglass frames Excellent	7. Variety of eyeglass frames Very Good	7. Variety of eyeglass frames Good	7. Variety of eyeglass frames Fair	7. Variety of eyeglass frames Poor	7. Variety of eyeglass frames N/A
8. Knowledge/assistance of optical staff	8. Knowledge/assistance of optical staff Excellent	8. Knowledge/assistance of optical staff Very Good	8. Knowledge/assistance of optical staff Good	8. Knowledge/assistance of optical staff Fair	8. Knowledge/assistance of optical staff Poor	8. Knowledge/assistance of optical staff N/A
9. Comfort and cleanliness of office	9. Comfort and cleanliness of office Excellent	9. Comfort and cleanliness of office Very Good	9. Comfort and cleanliness of office Good	9. Comfort and cleanliness of office Fair	9. Comfort and cleanliness of office Poor	9. Comfort and cleanliness of office N/A
10. Overall satisfaction with your visit	10. Overall satisfaction with your visit Excellent	10. Overall satisfaction with your visit Very Good	10. Overall satisfaction with your visit Good	10. Overall satisfaction with your visit Fair	10. Overall satisfaction with your visit Poor	10. Overall satisfaction with your visit N/A

Will you be returning to see us?

Will you be returning to see us? Yes

Uncertain

Other (please specify)

Would you recommend us to others?

Would you recommend us to others? Yes

Uncertain

Other (please specify)

How can we improve? Please enter any comments or suggestions below:

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