1. Default Section

* 1. Please Complete the Following:

* 2. What was your

Treatment date?
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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?
How would you rate our staff’s explanation of your evaluation and surgery procedure?
How would you rate our Refractive Surgery Coordinator’s availability via phone?
How would you rate the explanation of your surgery by the physician and his or her staff?
How would you rate the overall professionalism of the physician?
How would you rate the physician’s ability and willingness to answer your questions?
How would you rate the courteousness of the physician?
How would you rate the explanation of instruments to be used during treatment?
How would you rate your satisfaction with answers given to you regarding your treatment?
How would you rate the instructions given to you for follow-up care (i.e. use of medications, eye drops, activity limitations, etc.)?

* 5. Please rate the following:

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

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