1) What was the purpose of your visit to our office?

Routine Exam
Follow Up Visit
Pre Or Post Surgical
Referred By My Doctor
Other

2) How satisfied were you with the way you were treated by our staff?

Very Satisfied
Somewhat Satisfied
Undecided
Somewhat Dissatisfied
Very Dissatisfied

3) How satisfied were you with the way you were treated by our doctors?

Very Satisfied
Somewhat Satisfied
Undecided
Somewhat Dissatisfied
Very Dissatisfied

4) How satisfied were you with the amount of time you had to wait before being seen?

Very Satisfied
Somewhat Satisfied
Undecided
Somewhat Dissatisfied
Very Dissatisfied

5) How would you rate the accessibility of our location?

Excellent
Good
Fair
Poor
Don't Know

6) How did you hear about Eye Surgeons & Physicians (please check all that apply)?

Billboard
Newspaper
Magazine
Radio
Yellow Pages
Referral
Word of Mouth
Other

7) Overall, how would you rate your visit to our office?

Very Positive
Somewhat Positive
Undecided
Somewhat Negative
Very Negative

8) Would you recommend us to family and friends?

Yes
No
(If no, please list reasons why: )

9) Please tell us what, if anything, we can do to improve your experience at Eye Surgeons & Physicians.