Please help us recognize our doctors and staff for meeting your expectations or identify areas where we can improve by filling out this survey. At Schaeffer Eye Center we strive for 100% Patient Satisfaction, 100% of the time. Thank you for sharing your experience with us. We know your time is valuable, so we will randomly select one patient each month to win a pair of FREE sunglasses for filling out the survey!


Office Visited:


Doctor Seen:


Approximate Date of Your Visit:
       


Your Appointment

1. How soon were you able to get an appointment?
Less than 1 week
1 to 2 weeks
More than 2 weeks

2. How long did you wait before testing began by a technician or doctor?
Under 15 minutes
15 to 30 minutes
More than 30 minutes

How would you rate the office on the following:

3. Answering or returning calls or emails promptly?
Not Good Good Very Good Excellent Exceptional Not Applicable

4. Getting your appointment as soon as you wanted?
Not Good Good Very Good Excellent Exceptional Not Applicable

5. Appeal of the office?
Not Good Good Very Good Excellent Exceptional Not Applicable

6. Keeping appointment on time?
Not Good Good Very Good Excellent Exceptional Not Applicable


Your Eye Doctor

How would you rate the eye doctor on the following:

7. Being professional?
Not Good Good Very Good Excellent Exceptional Not Applicable

8. Showing a personal interest in you?
Not Good Good Very Good Excellent Exceptional Not Applicable

9. Speaking Clearly?
Not Good Good Very Good Excellent Exceptional Not Applicable

10. The amount of time spent with you?
Not Good Good Very Good Excellent Exceptional Not Applicable

11. Being willing to explain your eye care?
Not Good Good Very Good Excellent Exceptional Not Applicable



How would you rate the eye doctor’s staff on:

12. Being Courteous?
Not Good Good Very Good Excellent Exceptional Not Applicable

13. Being knowledgeable about office procedures?
Not Good Good Very Good Excellent Exceptional Not Applicable

14. Using good hygiene?
Not Good Good Very Good Excellent Exceptional Not Applicable

15. Being helpful?
Not Good Good Very Good Excellent Exceptional Not Applicable

16. Respecting your privacy?
Not Good Good Very Good Excellent Exceptional Not Applicable

17. Overall how satisfied are you with the eye doctor?
Not Mostly Very Much ExtremelyCompletely Not Applicable

18. How likely is it that you will recommend this eye doctor if asked?
Unlikely Likely Very Likely Extremely Likely Definitely Not Applicable

19. Please let us know what you liked or what could be improved about your medical experience?




Your Optical Experience (Purchase of glasses and/or lenses)

20. How soon was your eyewear ready?
Same Day
1 to 3 Days
3 to 7 Days
7 to 10 Days
More than 10 Days

How would you rate the optical staff on:

21. Helping you choose frames?
Not Good Good Very Good Excellent Exceptional Not Applicable

22. Offering a variety of eyeglass frames to choose from?
Not Good Good Very Good Excellent Exceptional Not Applicable

23. Explaining the use and care of your new eyeware?
Not Good Good Very Good Excellent Exceptional Not Applicable

24. Explaining your costs?
Not Good Good Very Good Excellent Exceptional Not Applicable

25. Overall how satisfied are you with the optical experience?
Not Mostly Very Much ExtremelyCompletely Not Applicable

26. How likely is it that you will recommend this optical center?
Unlikely Likely Very Likely Extremely Likely Definitely Not Applicable

27. Please let us know what you liked or what could be improved about your optical experience?

About You (We will not share your information with any third party)

First Name:

Last Name:

Date of Birth

       

Would you like someone to contact you about your experience at Schaeffer Eye Center?
Yes No