Feedback Form
Please feel free to take the time to fill out the below feedback form. All your responses are anonymous unless you want to provide us your contact information. We greatly appreciate your feedback.
Date of your encounter: Time of your encounter:
How were you treated on the phone?
poor
average
good
excellent
not applicable
How were you treated when you first entered the office?
poor
average
good
excellent
not applicable
How was your experience in our office?
poor
average
good
excellent
not applicable
How do you feel you were treated?
poor
average
good
excellent
Is there any staff member that made your experience more enjoyable or less enjoyable?
(Please explain)
Do you feel the Doctor took the appropriate time with you?
too little time
perfect amount of time
too much time
not applicable
Do you feel the Doctor gave you the appropriate care?
unsatsifactory
satsifactory
exceeded expectations
not applicable
Do you feel the selection of glasses or products available fulfilled your needs?
(Please explain)
Is there any suggestion(s) you have to improve your experience the next time you are in to see us?
Any additional comments:
OPTIONAL INFORMATION
This section is optional, and should only be provided if you would like to be contacted on this matter.
Your Name:
Your Email:
Your Phone:
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