Patient Satisfaction Survey

Instructions

You must be 18 years or older to complete our survey. Plase rate the following questions using the rating scale below:

5 One of the best experiences I've had in a Doctor's office
4 Better than most experiences in other offices
3 About the same as other offices I've visited
2 Worse than in other offices I've visited
1 I wouldn't return
N/A Not Applicable

Note: All fields are required unless marked with *.

1) How professional and courteous was our staff on the phone?
5	4	3			2	1	N/A

2) How easy was it when you called to get the proper person or department?
5	4	3			2	1	N/A

3) During your office visit, how well did we listen to your specific needs?
5	4	3			2	1	N/A

4) How well were you educated on the vision tests and exams you received?
5	4	3			2	1	N/A

5) How would you rate the value of the services and products you received?
5	4	3			2	1	N/A

6) How courteous and professional was our staff during every aspect of your visit?
5	4	3			2	1	N/A

7) How well did we follow up with you if you ordered contacts or glasses?
5	4	3			2	1	N/A

8) Would you recommend our practice to your family and friends?
Yes	No

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

10) Overall, do you believe the time you spent in our office was (check one):
Comprehensive, just what I thought.
Too long, could have taken less time.
Too short, not enough time taken with my specific needs.

11) How did you first hear about Eye Care Associates?
Television				Promotional Flyer/Mailer
Radio				Internet Search
Yellow Pages				Referral from Friend/Family
Newspaper				Referral from Employer
Insurance Plan Book/Website				Window Sign
Vision Screening				Other
Location of Office

12) If you purchased eyewear somewhere other than Eye Care Associates, 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 explain below)
Also, please tell us where you made your purchase:

13) If you purchased contacts somewhere other than Eye Care Associates, 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 explain below)
Also, please tell us where you made your purchase:

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

15) Would you like for us to contact you in regards to a specific issue?
Yes	No

* Date of Your Office Visit


* Doctor			Office Location


Purpose of Visit


Enter Comments Below:*

* Patient Name:
* Relationship to Patient:
Your First Name:
Your Last Name:
Are you 18 or older?	Yes No

Address:
* Home Phone:	() -
Work Phone:	() - Ext:*
	Best Time To Call: Morning Afternoon Evening
* E-Mail:
Mobile/Other:*
Please type "gjjaj" without the quotes:

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