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Dear Patient,

We appreciate you taking the time to complete our survey. Please feel free to comment on your overall experience with us as well. When you are finished, click on the "submit survey" button at the bottom of the page.

Thank You.
Today:
Name (optional):
Doctor's Name:
1. Are you?
A new patient A returning patient
2. When you telephoned our office, did the receptionist answer your call courteously?
Yes No
3. When telephoning our office, have you been put on hold for long periods of time?
Yes No
4. Upon arrival, did the receptionist greet you courteously?
Yes No
5. Were our assistants courteous, pleasant and helpful?
Yes No
6. Were our assistants neat in appearance and dress?
Yes No
7. From your appointment time, how long did you wait before being seen by the doctor?
If it was a long time, were you given a reason for the delay?
Yes No
8. Were you satisfied with the level of care and attention you received?
Yes No
9. How would you rate the doctors on patience, warmth and interest in your problem?
Outstanding Good Average Poor
10. Did you understand the doctor's explanation of the results of your office visit?
Yes No
11. Did you have difficulty completing our forms upon arrival?
Yes No
12. After hours, have you ever had difficulty in reaching the doctor in an emergency?
Yes No
13. If you had and questions concerning your bill, did our billing department answer them in a thorough and courteous manner?
Yes No
14. If you chose to use our optical department, were our assistants courteous, pleasant and helpful?
Yes No
15. If you did not choose to use our optical department, why?
Pricing Service
Convenience Other
Comments:
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