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Comments Form

In effort to keep patient satisfaction high, we offer you a chance to give us feedback on your experiences in our office.  By filling out the following evaluation you are helping us to better meet your eye care needs.

If a question does not apply to you, it can be left unanswered.


1. Were you greeted warmly and treated well by the staff? Yes No
If not, please explain:
2. Were you seen in a timely manner? Yes No
If not, please explain:
3. Was your examination thorough? Yes No
If not, please explain:
4. Do you feel you received a thorough explanation of conditions or treatment options necessary? Yes No
If not, please explain:
5. If you wear contact lenses, did you find your technician helpful? Yes No
If not, please explain:
6. Were all your questions answered adequately? Yes No
If not, please explain:
7. If you wear glasses, did you find your optician helpful? Yes No
If not, please explain:
8. Did he or she answer all your questions adequately during your selection of eyewear? Yes No
If not, please explain:
9. Would you refer a friend to our office? Yes No
If not, please explain:
10. How did you hear about our office?
11. How would you rate your overall experience with our office?
12. What was the most memorable thing that happened in our office?
13. Any other comments?
Name (optional):  



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