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It is our desire to provide you with excellent customer service. Would you please take 60 seconds to fill out these questions to let us know how we are doing?
Date of the appointment you are rating
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How would you rate your experience with the following departments in our office? (On a scale with 1=Poor to 10=Excellent, please rate the below departments)
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Front Desk/Check-In
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Clinic (Doctors and Technicians)
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Optical/Contacts
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Check Out
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Did we exceed all of your
expectations today?
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Yes
No
If not, how can we better serve you in the future?
Did anyone provide exceptional service to you today? If so, please provide the name or department.
Was anyone less than courteous to you today? If so, please provide the name or department.
Please leave us any additional comments that will help us to serve you in the future:
Name
Email Address