Patient Satisfaction Survey

1. How quickly do we attend to you?

2. How easy is it to get to our office?

3. During a typical office visit, do we spend the right amount of time with you?

4. Do you trust our doctor to make medical decisions that are in your best interests?

5. How well do we answer your questions?

6. How satisfied are you with our staff?

7. How satisfied are you with the quality of your eyewear?

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?

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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