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WORKING WITH US |
Scale
(5=Outstanding
/
1=Poor) |
|
1. |
You were treated
politely when you first
contacted us. |
5
4
3
2
1
n/a
|
|
2. |
We are conveniently
located. |
5
4
3
2
1
n/a
|
|
3. |
We offer convenient
appointment times. |
5
4
3
2
1
n/a
|
|
4. |
We greeted you, were
helpful, and you
were seen promptly. |
5
4
3
2
1
n/a
|
|
5. |
The office is clean,
tidy, and comfortable. |
5
4
3
2
1
n/a
|
|
6. |
We are easy to do
business with. |
5
4
3
2
1
n/a
|
|
7. |
Our staff was
professional,
knowledgeable, and
attentive to your needs. |
5
4
3
2
1
n/a
|
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YOUR EYE EXAM |
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|
8. |
Your pretesting and eye
exam was thorough,
unhurried, with easy to
understand explanations. |
5
4
3
2
1
n/a
|
|
9. |
Your doctor thoroughly
explained your eye
health exam results, and
answered any questions. |
5
4
3
2
1
n/a
|
|
10. |
Your doctor was
interested in you and
your concerns. |
5
4
3
2
1
n/a
|
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OUR PRODUCTS |
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|
11. |
We had a good selection
of eyewear in all price
ranges. |
5
4
3
2
1
n/a
|
|
12. |
Our eyewear prices, your
insurance coverages, and
our billing process was
easy to understand. |
5
4
3
2
1
n/a
|
|
13. |
Your fees were
accurately billed. |
5
4
3
2
1
n/a
|
|
14. |
Your optician was
friendly, attentive, and
found you the perfect
frame in the price range
you wanted. |
5
4
3
2
1
n/a
|
|
15. |
Your eyeglasses fit and
look perfect when
delivered. |
5
4
3
2
1
n/a
|
|
16. |
Your eyewear order was
ready when promised, in
a period of time that
was better than average. |
5
4
3
2
1
n/a
|
|
17. |
You are completely
satisfied with your new
eyewear. |
5
4
3
2
1
n/a
|
|
18. |
Your contact lens exam
was thorough and
accurate. |
5
4
3
2
1
n/a
|
|
19. |
Your contacts were
ordered and delivered in
better than average
time. |
5
4
3
2
1
n/a
|
|
20. |
You feel that your new
contacts provide
excellent vision and
comfort. |
5
4
3
2
1
n/a
|
|
21. |
You received good value
in your contacts. |
5
4
3
2
1
n/a
|
|
22. |
You received good value
in your glasses. |
5
4
3
2
1
n/a
|
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SUMMARY |
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23. |
You are likely to
recommend a friend or
family member to us for
professional eye care,
contacts, and eyewear. |
5
4
3
2
1
n/a
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Please share with us any
problems you had, or
compliments for
extraordinary service:... |
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Can we contact you for
more details in order to
solve a problem?
Yes
No |
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Best time to call -
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Name -
Phone -
Email Address -
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