Patient Satisfaction Survey

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* 1. Please provide the following information:

Full Name:

Address:

Address 2:

City/Town:

State:

ZIP/Postal Code:

Email Address:

Phone Number:

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* 2. Please enter date of your

Office Visit

Date

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* 3. Please select the Doctor that you saw

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* 4. Please select the office where your visit was

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* 5. What was the purpose of your visit?

Complete Eye Exam

Contact Lens Exam

Eye Glass Fitting

LASIK Consultation

Eye Health Concern

Cataract Evaluation

Other (please specify)

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* 6. Was this your first visit?

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* 7. How long did you have to wait in the waiting room on the day of your appointment?

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* 8. Please rate the following:

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

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* 9. If you purchased in our optical department, what did you purchase?

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* 10. How long did your optical order take?

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* 11. If applicable, were you notified of any delays or backorders?

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

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

Yes

Other (please specify)

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

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

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* 16. Overall, do you believe the time you spent in our office was:

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* 17. How did you first hear about D'Ambrosio Eye Care?

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* 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):

Service

Price

Selection

Didn't want new glasses this year

Other (please specify)

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* 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):

Service

Price

Selection

Didn't want new contacts this year

Other (please specify)

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

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

Yes

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

Yes

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* 1. Please provide the following information:

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* 2. Please enter date of your

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* 3. Please select the Doctor that you saw

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* 4. Please select the office where your visit was

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* 5. What was the purpose of your visit?

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* 6. Was this your first visit?

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* 7. How long did you have to wait in the waiting room on the day of your appointment?

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* 8. Please rate the following:

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* 9. If you purchased in our optical department, what did you purchase?

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* 10. How long did your optical order take?

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* 11. If applicable, were you notified of any delays or backorders?

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

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

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

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

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* 16. Overall, do you believe the time you spent in our office was:

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* 17. How did you first hear about D'Ambrosio Eye Care?

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* 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):

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* 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):

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

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

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

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* 23. May we use your name?