Patient Feedback Form

As a valued customer we would be very grateful if you would complete the following to help us improve our service to you and receive entry in to our prize draw to win a £50 Simmons voucher for you or your family.

100% of survey complete.

Question Title

* 1. Contact Information

This will allow us to reply to any concerns you may have and enter you into the prize draw for a £50 Simmons Optometrists voucher.

Name:

Email Address:

Phone Number:

Question Title

* 2. How easy do you find making an appointment or getting in touch with us?

	Excellent	Good	Average	Could be better	Poor
Please select one	Please select one Excellent	Please select one Good	Please select one Average	Please select one Could be better	Please select one Poor

Please tell us why / any suggestions

Question Title

* 3. How would you rate your welcome on arrival for an appointment or when visiting the practice?

	Excellent	Good	Average	Could do better	Poor
Please select one	Please select one Excellent	Please select one Good	Please select one Average	Please select one Could do better	Please select one Poor

Please tell us why

Question Title

* 4. How do you rate your experience with your optometrist in the consulting room?

	Excellent	Good	Average	Could be better	Poor	N/A
Please select one	Please select one Excellent	Please select one Good	Please select one Average	Please select one Could be better	Please select one Poor	Please select one N/A

Please tell us why

Question Title

* 5. How do you rate your experience when choosing glasses, with regard to advice and help?

	Excellent	Good	Average	Could be better	Poor	N/A
Please select one	Please select one Excellent	Please select one Good	Please select one Average	Please select one Could be better	Please select one Poor	Please select one N/A

Please tell us why

Question Title

* 6. How do you rate your experience when collecting your glasses or contact lenses?

	Excellent	Good	Average	Could be better	Poor	N/A
Please select one	Please select one Excellent	Please select one Good	Please select one Average	Please select one Could be better	Please select one Poor	Please select one N/A

Please tell us why

Question Title

* 7. How do you rate the overall level of service you receive from us?

	Excellent	Very good	Average	Could do better	Poor
Please select one	Please select one Excellent	Please select one Very good	Please select one Average	Please select one Could do better	Please select one Poor

Please tell us why

Question Title

* 8. How do rate the range of frames to choose from?

	Excellent	Good	Average	Could be better	Poor	N/A
Please select one	Please select one Excellent	Please select one Good	Please select one Average	Please select one Could be better	Please select one Poor	Please select one N/A

Please tell us why / are there any ranges you would like us to stock?

Question Title

* 9. How do you rate the overall value for money you receive at Simmons?

	Excellent	Good	Average	Could be better	Poor
Please select one	Please select one Excellent	Please select one Good	Please select one Average	Please select one Could be better	Please select one Poor

Please tell us why

Question Title

* 10. How likely is it that you would recommend Simmons Optometrists to a friend or colleague?

	0 - Not at all likely	1	2	3	4	5	6	7	8	9	10 - Extremely likely
Please select one	Please select one 0 - Not at all likely	Please select one 1	Please select one 2	Please select one 3	Please select one 4	Please select one 5	Please select one 6	Please select one 7	Please select one 8	Please select one 9	Please select one 10 - Extremely likely

Please tell us why