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* 1. Please provide the following information:

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* 2. Please enter in the date of your office visit

MM/DD/YYYY

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* 5. What was the purpose of your visit (please select all that apply)

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* 6. Please rate the following questions

  Excellent Good Average Poor Awful 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 physicians during every aspect of your visit?
If you ordered glasses or contacts, did the process and the overall experience meet your expectations?

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

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* 8. Would you recommend our practice to your family and friends?

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

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* 12. If you purchased eyewear somewhere other than the Baltimore Washington Eye Center, which of the following best describes the reason why you chose not to purchase from us (check all that apply):

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* 13. If you purchased contacts somewhere other than the Baltimore Washington Eye Center, which of the following best describes the reason why you chose not to purchase from us (check all that apply):

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

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

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