Anonymous Customer Survey

Quality customer service is something we’re always striving to improve.
We value your input and appreciate you taking time to give us this feedback.

Service Date

Your Age Range
Assistant
Optometrist
How do you rate your experience
Would you recommend our office?

Indicate your level of agreement with the following statements

The Optometrist was:	Courteous -	Professional -	Knowledgeable -

The Assistant was:	Courteous -	Professional -	Knowledgeable -

Please Rate your experience during this visit for the Following - '1' being the worst and '5' the best

Wait time
Scheduling
Office hygiene

Please Rate the Following in Terms of Importance for a medical office visit in general (not related to this visit) - '1' being the least and '5' the most important - this is to help us know where to focus our efforts.

Wait time
Friendliness of Staff
Professional Demeanor

Please write any additional comments below.
If you would like to be contacted include your name and phone number.