Web Survey

Patient Satisfaction Survey

Your comments help us maintain a high quality of service. Please tell us what you think.

If you are already one of our patients, thank you for
letting us provide your eyecare.

If you are not one our patients now please consider
allowing us to provide your eyecare in the future.

Have you been to our office more than once?

Yes

No

Please choose the best answer for each of the following.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
The staff was friendly
The staff was eager to help me
The Doctor was friendly
The Doctor answered my questions
The examination was throrough
I will return in the future
I will refer my family and friends

Overall, how satisfied were you with your visit to our office?

Comments or Suggestions

First Name

Last Name

Phone

Email Address

* Indicates Response Required