PATIENT SATISFACTION SURVEY
 
 

Your satisfaction is important to us. Please fill in the below survey and let us know if we did well for you or if there are areas we can improve.  When done, click "Submit Patient Survey" button at the bottom. 

All information fields are required *.
How did you find us :
Team Sponsor
Yellow Pages
Race Sponsor
Other
Do you feel we were attentive to your eye care needs: (Choose all that apply)?
At the front desk  
During the exam
When choosing your Glasses or Contacts
When picking up your Glasses or Contacts
Were you able to make your appointment at a convenient time?
Very convenient   
Somewhat convenient
Inconvenient  
Do you feel the staff clearly understood your concerns: (Choose all that apply)
Did our staff keep their promises with regards to: (Choose all that apply)
On time for scheduled appointment
Price quoted was price paid
Glasses/Contacts ready when promised
Visual expectations met with Contacts/Glasses
Did the office: (Choose all that apply)
Confirm your appointment
Please check box if appointment was scheduled within 2 days of your visit.
Notify you that your Glasses/Contacts were ready on or before promised date
Make a follow up call after picking up your Glasses/Contacts
Was the staff and your experience:
Friendly and Inviting
Indifferent
Unfriendly
Were you treated with respect: (Choose all that apply):
By the front desk
By the technician performing pre-exam testing
By the doctor
By the opticians
Were your eyewear options presented?
In a professional manner
In a less than professional manner
In an unprofessional manner
Was your order processed correctly the first time?
Yes
No
Were we helpful in obtaining information about your insurance and explaining coverage?
Yes
No
How would you rate the overall value of your contact lens or eyeglass purchase:
Better than expected
Met Expectations
Less than expected
Will you return to Eagle Eye Associates in the future for your eye care needs?
Yes
No
If no, please explain:
Will you recommend us to a friend?
A. Yes
B. No
In striving to be the best provider for your eye care needs, we ask that you share any additional thoughts with us below:
Email: Required
Full Name:
Day time phone number:

 
 

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