Question Title

* 1. Please provide the following information:

Question Title

* 2. Please enter date of your

Office Visit

Question Title

* 5. What was the purpose of your visit?

Question Title

* 8. Please rate the following:

  Excellent Average Poor N/A
How professional and courteous was our staff on the phone?
How easy was it when you called to get the proper person or department?
During your office visit, how well did we listen to your specific needs?
How well were you educated on the vision tests and exams you received?
How courteous and professional was our front desk staff during every aspect of your visit?
How courteous and professional were our technicians during every aspect of your visit?
How courteous and professional were our doctors during every aspect of your visit?
If you ordered glasses or contacts, are you satisfied with your order and experience?
If you had cause to speak to one of our billing clerks how courteous and professional were they during every aspect of your conversation?

Question Title

* 12. Tell us how we can improve our optical, eyewear and contact lens services.

Question Title

* 13. Were you satisfied with the appearance, atmosphere and accommodations of our office?

Question Title

* 15. Do you have any recommendations that could improve the performance of our office?

Question Title

* 18. If you purchased eyewear somewhere other than D'Ambrosio Eye care, which of the following best describes the reason why you chose not to purchase from us (check all that apply):

Question Title

* 19. If you purchased contacts somewhere other than D'Ambrosio Eye Care, which of the following best describes the reason why you chose not to purchase from us (check all that apply):

Question Title

* 20. Are there any individuals that you would like to recognize for their service?

Question Title

* 21. Would you like for us to contact you in regards to a specific issue?

Question Title

* 22. Do we have your permission to share your comments or opinion with others in print and electronically?

Question Title

* 23. May we use your name?

T