Patient Satisfaction Survey
Instructions:
          You must be 18 years of age or older to complete our survey.
Please use this scale when answering the questions:
   5.   One of the best experiences I've had when in a doctor's office
   4.   Better than most experiences I've had in other offices
   3.   About the same as I've experienced in other offices
   2.   Worse than in other offices I've visited
   1.   I wouldn't return
Questions:
     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 well were your vision plan and benefits explained?
 
5
4
3
2
1
N/A		  
  5. How would you rate the value of the services and products you received?
 
5
4
3
2
1
N/A		  
  6. How courteous and professional was our staff during every aspect of your visit?
 
5
4
3
2
1
N/A		  
  7. How satisfied were you with the ability of My Eye Dr. to have your glasses or contact lenses ready when promised?
 
5
4
3
2
1
N/A		  
  8. Would you recommend our practice to your family and friends?
  Yes       No
  9. Were you made aware that you could complete/update your patient history with an on-line form that would
reduce your time spent in the office?
  Yes       No
  10. What did you like best about your office experience?
 
* 11. If you have recommendations that could improve the performance of the office, please provide them.
 
  12. Overall, do you believe the time you spent in the office was:
  a. Comprehensive, just what I thought
  b. Too long, could have taken less time
  c. Too short, not enough time taken with my specific needs
  13. How did you first hear about MyEyeDr?
  a. Radio
  b. Yellow Pages
  c. Insurance Plan
  d. Vision Screening
  e. Location of Office
  f. Promotional Flyer/Mailer
  g. Internet Search
  h. Referral from Friend/Family
  i. Referral from Employer
  j. Television Ad
  k. Other
* 14. If you did not purchase eyewear or contacts from My Eye Dr., which of the following best describes the reason
why you chose not to purchase from us (check all that apply):
  Service
  Selection
  Price
  Didn't want new glasses or contacts this year
  Other (please explain below)
  If you purchased glasses or contacts elsewhere, please tell us where you made your purchase:
 
* 15. Are there any individuals that you would like to recognize for their service?
 
  16. Would you like to receive e-mails from us about upcoming sales, trunk shows, eye health issues, etc?
  Yes       No
  Email Address:
Information about the Visit:
  Date of Office Visit:
  Location Visited:
  Purpose of Visit?
  Yearly Eye Exam
  Blurred Vision / Emergency Visit
Personal Information:
  Patient Name:
  Your relationship to the patient?
    Parent
    Spouse
    Self
  Your First Name:
  Are you 18 or older?
    Yes       No
Please note, this survey will be thoroughly read by a representative of our company. However, it will not solicit a direct
response. Since exceeding each and every patient's expectations with our service and products is our goal, if you
would like to be contacted by a My Eye Dr. representative in regards to an experience or issue, we encourage you to
email us directly at inquiry@myeyedr.com.