* 1. How did you hear about Retina Consultants of Southwest Florida?

* 2. Which office did you visit today?

* 3. Do you use a computer?

* 4. If yes, may we contact you through email?

* 5. If you use a computer, do you visit any of the following social networking sites? Please select all that apply

* 6. Have you visited Retina Consultants of Southwest Florida's website? www.eye.md

* 7. Have you visited National Ophthalmic Research Institute's website? www.nori.md

* 8. Please indicate your level of satisfaction concerning the following appointment making steps.

  Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Extremely Dissatisfied Not Applicable
Courtesy of staff member
Ease in scheduling
Amount of time placed on hold
Music/Dialogue played while on hold
Any questions you had were answered to your satisfaction

* 9. Before your appointment, were you notified that your appointment would last about 2 to 3 hours?

* 10. Is this your first visit to Retina Consultants of Southwest Florida?

* 11. Please describe your experience when you first entered our office.

  Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Extremely Dissatisfied Not Applicable
Greeted promptly
Greeted politely
Checked in quickly
Checked in politely
Any questions you had were answered to your satisfaction

* 12. Please describe your experience with your insurance coverage or your account manager during your visit.

  Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Extremely Dissatisfied Not Applicable
I was advised about my insurance coverage prior to any services rendered
I was given the opportunity to speak with an account manager
Any questions I had were answered to my satisfaction

* 13. Please describe your satisfaction with our medical staff.

  Extremely satisfied Satisfied Somewhat satisfied Somewhat dissatisfied Extremely dissatisfied Not Applicable
Amount of time waiting prior to being called back initially
Politeness of staff member checking vision
Politeness of staff member assisting doctor
Politeness of doctor
Testing or procedures explanation
Diagnosis and potential treatment options explanation
Patient Brochures
Instructions Explanation at the End of Appointment

* 14. Approximately how long did you wait before being examined by your doctor?

* 15. In your opinion, was the amount of time spent with the doctor sufficient?

* 16. Please describe your check out experience.

  Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Extremely Dissatisfied Not Applicable
Checked out promptly
Checked out politely
Ease of scheduling next appointment

* 17. Please describe the appearance/hospitality of our office.

  Extremely Satisfied Satisfied Somewhat Satisfied Dissatisfied Extremely Dissatisfied Not Applicable
Decor
Cleanliness
Refreshments
Restrooms
Lighting
Television stations in the waiting areas
Noise Level

* 18. Please describe your experience in our office overall.

  Strongly Agree Agree Somewhat Agree Disagree Strongly Disagree Not Applicable
Do you feel as if we respected your privacy/personal Information?
Would you recommend Retina Consultants to your family or friends?
Do you feel as if your experience at Retina Consultants was as good as, if not better compared to other doctors' offices?

* 19. Were there any staff member(s) that were memorable during your visit? Please provide the name and why:

* 20. We hope that you will take a moment to share any other experiences so that we may better serve you in the future. We sincerely value your opinion and would appreciate any comments that you are willing to provide.

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