Patient Satisfaction Survey

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1. Please let us know which doctor you saw during your visit:

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2. When you called for an appointment, how would you rate:

	Poor	Fair	Average	Good	Very Good
Your experience with our appointment representative?	Your experience with our appointment representative? Poor	Your experience with our appointment representative? Fair	Your experience with our appointment representative? Average	Your experience with our appointment representative? Good	Your experience with our appointment representative? Very Good
The availability of appointment times?	The availability of appointment times? Poor	The availability of appointment times? Fair	The availability of appointment times? Average	The availability of appointment times? Good	The availability of appointment times? Very Good

Comments:

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3. When you arrived at the office, how would you rate:

	Poor	Fair	Average	Good	Very Good
Our patient representative?	Our patient representative? Poor	Our patient representative? Fair	Our patient representative? Average	Our patient representative? Good	Our patient representative? Very Good
The timeliness of the check-in process?	The timeliness of the check-in process? Poor	The timeliness of the check-in process? Fair	The timeliness of the check-in process? Average	The timeliness of the check-in process? Good	The timeliness of the check-in process? Very Good

Comments:

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4. How satisfied were you with the amount of time spent:

	Poor	Fair	Average	Good	Very Good
In the reception area?	In the reception area? Poor	In the reception area? Fair	In the reception area? Average	In the reception area? Good	In the reception area? Very Good
Doctor's waiting area?	Doctor's waiting area? Poor	Doctor's waiting area? Fair	Doctor's waiting area? Average	Doctor's waiting area? Good	Doctor's waiting area? Very Good
In the examination room?	In the examination room? Poor	In the examination room? Fair	In the examination room? Average	In the examination room? Good	In the examination room? Very Good

Comments

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5. When you were called to the examination room, did you find your nurse/technician to be:

	Poor	Fair	Average	Good	Very Good
Friendly and courteous?	Friendly and courteous? Poor	Friendly and courteous? Fair	Friendly and courteous? Average	Friendly and courteous? Good	Friendly and courteous? Very Good
Competent and professional?	Competent and professional? Poor	Competent and professional? Fair	Competent and professional? Average	Competent and professional? Good	Competent and professional? Very Good
Sympathetic and caring?	Sympathetic and caring? Poor	Sympathetic and caring? Fair	Sympathetic and caring? Average	Sympathetic and caring? Good	Sympathetic and caring? Very Good

Comments

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6. During your examination, did you find your doctor to be:

	Poor	Fair	Average	Good	Very Good
Friendly and courteous?	Friendly and courteous? Poor	Friendly and courteous? Fair	Friendly and courteous? Average	Friendly and courteous? Good	Friendly and courteous? Very Good
Competent and professional?	Competent and professional? Poor	Competent and professional? Fair	Competent and professional? Average	Competent and professional? Good	Competent and professional? Very Good
Sympathetic and caring?	Sympathetic and caring? Poor	Sympathetic and caring? Fair	Sympathetic and caring? Average	Sympathetic and caring? Good	Sympathetic and caring? Very Good

Comments

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7. How satisfied were you with:

	Poor	Fair	Average	Good	Very Good	N/A
Your doctor's diagnosis?	Your doctor's diagnosis? Poor	Your doctor's diagnosis? Fair	Your doctor's diagnosis? Average	Your doctor's diagnosis? Good	Your doctor's diagnosis? Very Good	Your doctor's diagnosis? N/A
Your doctor's recommendation for surgery/treatment?	Your doctor's recommendation for surgery/treatment? Poor	Your doctor's recommendation for surgery/treatment? Fair	Your doctor's recommendation for surgery/treatment? Average	Your doctor's recommendation for surgery/treatment? Good	Your doctor's recommendation for surgery/treatment? Very Good	Your doctor's recommendation for surgery/treatment? N/A
The information and detail regarding available surgery/treatment options?	The information and detail regarding available surgery/treatment options? Poor	The information and detail regarding available surgery/treatment options? Fair	The information and detail regarding available surgery/treatment options? Average	The information and detail regarding available surgery/treatment options? Good	The information and detail regarding available surgery/treatment options? Very Good	The information and detail regarding available surgery/treatment options? N/A

Comments

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8. If you visited our optical department, how would you rate:

	Poor	Fair	Average	Good	Very Good	N/A
Our opticians?	Our opticians? Poor	Our opticians? Fair	Our opticians? Average	Our opticians? Good	Our opticians? Very Good	Our opticians? N/A
The frame selection?	The frame selection? Poor	The frame selection? Fair	The frame selection? Average	The frame selection? Good	The frame selection? Very Good	The frame selection? N/A

Comments

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9. Following your appointment, how would you rate your experience with:

	Poor	Fair	Average	Good	Very Good	N/A
The check-out representative?	The check-out representative? Poor	The check-out representative? Fair	The check-out representative? Average	The check-out representative? Good	The check-out representative? Very Good	The check-out representative? N/A
The billing/insurance representative?	The billing/insurance representative? Poor	The billing/insurance representative? Fair	The billing/insurance representative? Average	The billing/insurance representative? Good	The billing/insurance representative? Very Good	The billing/insurance representative? N/A

Comments

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10. Regarding your overall experience with Johnson City Eye Clinic:

	Poor	Fair	Average	Good	Very Good
How would you rate your overall experience?	How would you rate your overall experience? Poor	How would you rate your overall experience? Fair	How would you rate your overall experience? Average	How would you rate your overall experience? Good	How would you rate your overall experience? Very Good
How likely would you be to recommend our practice to your friends?	How likely would you be to recommend our practice to your friends? Poor	How likely would you be to recommend our practice to your friends? Fair	How likely would you be to recommend our practice to your friends? Average	How likely would you be to recommend our practice to your friends? Good	How likely would you be to recommend our practice to your friends? Very Good

Comments