Patient Satisfaction Survey

Our goal is to provide you with an exceptional experience when you visit Schaeffer Eye Center. That mission is accomplished through a team effort of many individuals who are committed to your total satisfaction.

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Prizes Awarded!

Your input is very important to us. Participate in our Patient Satisfaction Survey and you will be entered into a drawing held every two months for a pair of free sunglasses. March/April Featured Frames are provided by Fendi.

We respect your privacy, therefore your personal information is never shared with parties outside of Schaeffer Eye Center. However, we may contact you if you have an issue you would like resolved. We use survey information internally to improve our patient care practices and develop a patient-focused environment for you and your family. Please take a moment to let us know how we are doing.

Our January/February 2008 winner is Liliana G. from Huntsville, Ala.

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Instructions

You must be 18 years or older to complete our survey.
Please rate the following questions using the rating scale below:

5	One of the best experiences I've had in a Doctor's office
4	Better than most experiences in other offices
3	About the same as other offices I've visited
2	Worse than in other offices I've visited
1	I wouldn't return
N/A	Not Applicable

Note: All fields are required unless marked with *.

1.	How professional and courteous was our staff on the phone? 5   4   3   2   1   N/A
2.	During your office visit, how well did we listen to your specific needs? 5   4   3   2   1   N/A
3.	How well were you educated on the vision tests and exams you received? 5   4   3   2   1   N/A
4.	How would you rate the value of the services and products you received? 5   4   3   2   1   N/A
5.	How courteous and professional was our staff during every aspect of your visit? 5   4   3   2   1   N/A
6.	How well did we follow up with you if you ordered contacts or glasses? 5   4   3   2   1   N/A
7.	Would you recommend our practice to your family and friends? 5   4   3   2   1   N/A
8.	If you are a new patient, were you made aware that you can download patient forms at home from our Website in order to reduce your time spent in the office? Yes   No
9.	What did you like best about your experience in our office? *
10.	Do you have any recommendations that could improve the performance of our office? *
11.	Overall, do you believe the time you spent in our office was (check one): Comprehensive, just what I thought. Too long, could have taken less time. Too short, not enough time taken with my specific needs.
12.	How did you first hear about Schaeffer Eye Center? Television Radio Yellow Pages Newspaper Insurance Plan Book/Website Vision Screening Location of Office Promotional Flyer/Mailer Internet Search Referral from Friend/Family Referral from Employer Window Sign Other
13.	If you purchased eyewear somewhere other than Schaeffer Eye Center, which of the following best describes the reason why you chose not to purchase from us (check all that apply):* N/A Service Price Selection Didn't want new glasses/contacts this year Other (Please Explain Below) Also, please tell us where you made your purchase:
14.	Are there any individuals that you would like to recognize for their service?*
15.	Would you like for us to contact you in regards to a specific issue? Yes No
16.	Date of Your Office Visit JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember     12345678910111213141516171819202122232425262728293031
17.	Doctor Please select Dr. James Begun Dr. Patrica Benjamin Dr. Wesley Dubose Dr. Rachel Harvey Dr. Amy Herrington Dr. Matthew James Dr. Stephanie Johnson Dr. Lisa Kennedy Dr. David King Dr. David O'Leary Dr. Nathan Parvin Dr. Jack Schaeffer Dr. Ernest Sisneros Dr. Frank Spalla Dr. Paul Vandiver Not sure
18.	Office Location Please select Birmingham-Hoover Birmingham-Colonnade Birmingham-Mt. Brook Birmingham-LaserVision Birmingham-Eastwood Birmingham-Southside Birmingham-Trussville Birmingham-Five Points West Birmingham-Riverchase Montgomery Huntsville-University Huntsville-Whitesburg Tuscaloosa Not sure
19.	Purpose of Visit Complete Eye Exam Contact Lens Exam Dry Eye Work Up Eye Glass Fitting Laser Surgery Evaluation Laser Surgery Eye Health Concern - Specify Below Other (Please Explain Below)
20.	Enter Comments Below:*
21.	Patient Name
22.	Relationship to Patient Self Spouse Parent Guardian Other
23.	Your First Name
24.	Your Last Name
25.	Are you 18 or older? Yes   No
26.	Address
27.	Home Phone
28.	Work Phone*
29.	Best Time to Call Morning Afternoon Evening
30.	E-Mail*
31.	Mobile/Other:*