CUSTOMER SATISFACTION SURVEY

Provider

Location
Doctor
Service Rating

1. Convenience of our office hours
Excellent Very Good Good Fair Poor
2. Ease of making your appointment
Excellent Very Good Good Fair Poor
3. Promptness with which you were seen by
the doctor
Excellent Very Good Good Fair Poor
4. Thoroughness of care you received
Excellent Very Good Good Fair Poor
5. Clarity of Doctor's explanations
Excellent Very Good Good Fair Poor
6. Doctor's friendliness and courtesy
Excellent Very Good Good Poor
7. Staff's friendliness and courtesy
Excellent Very Good Good Fair Poor
8. Help with understanding your insurance
coverage (if applicable)
Excellent Very Good Good Fair Poor
9. Service fees
Excellent Very Good Good Fair Poor
10. Selection of eyeglass frames
Excellent Very Good Good Fair Poor
11. Knowledge/assistance of optical staff
Excellent Very Good Good Fair Poor
12. Comfort and cleanliness of office
Excellent Very Good Good Fair Poor
13. Pricing of the frames and Lenses
Excellent Very Good Good Fair Poor
14. Overall satisfaction with your visit
Excellent Very Good Good Fair Poor
15. Will you be returning to see us?
Yes No
16. Overall satisfaction with your visit
Yes No
How can we improve? Please enter any comments or suggestions below:
Identification (Optional)

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Sex
Male Female
Age group