Patient Satisfaction Survey
1. How quickly do we attend to you?
Please select...
Extremely quickly
Very quickly
Moderately quickly
Slightly quickly
Not at all quickly
2. How easy is it to get to our office?
Please select...
Extremely easy
Very easy
Moderately easy
Slightly easy
Not at all easy
3. During a typical office visit, do we spend the right amount of time with you?
Please select...
Much too much
Somewhat too much
Slightly too much
About the right amount
Slightly too little
Somewhat too little
Much too little
4. Do you trust our doctor to make medical decisions that are in your best interests?
Please select...
A great deal
A lot
A moderate amount
A little
Not at all
5. How well do we answer your questions?
Please select...
Extremely well
Very well
Moderately well
Slightly well
Not at all well
6. How satisfied are you with our staff?
Please select...
Extremely satisfied
Quite satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Quite dissatisfied
Extremely dissatisfied
7. How
satisfied
are you with the quality of your eyewear?
Please select...
Extremely satisfied
Quite satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Quite dissatisfied
Extremely dissatisfied
8. If you are not completely
satisfied
with your current eyewear, what changes or options would interest you?
9. How likely are you to recommend our office to family or friends?
Please select...
Extremely likely
Very likely
Moderately likely
Slightly likely
Not at all likely
If you have someone in mind, please share their information so we can email them an invitation to our office. We will happily THANK YOU with a gift card of your choice when they visit our office. Gift cards are Starbucks, Wawa or AMC Movies.
Your friend, co-worker, or family member’s:
First Name:
John or Jane
Last Name:
Doe
Email Address:
jdoe@domain.com
We will never share any email address received with any third party, it is always private.
Please also share your name so we can
THANK YOU,
once your referral visits our office, with the gift card of your choice
.
Your First Name:
John or Jane
Your Last Name:
Doe
Your Email Address:
jdoe@domain.com
Comments:
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