Please select your answers to the following questions using a scale of 1 to 5, with 1 being poor service and 5 being extremely good service. Please skip questions that do not apply.

1. When you called for an appointment, were you satisfied with the response from the person who answered the telephone?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

2. When you arrived for your appointment, did you find the receptionist(s) in our office:
Friendly and Courteous?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So
Helpful?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

3. How acceptable was the amount of time spent in the reception area and examining room before seeing the doctor?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

4. When you were called to the examining room, did you find our technician: Friendly and Courteous?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So
Competent and Professional?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So
Sympathetic & Caring?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

5. During your examination, did you find the doctor to be:
Friendly and Courteous?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So
Competent and Professional?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So
Sympathetic & Caring?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

6. Did the doctor spend an appropriate amount of time with you, answer your questions and explain medical procedures to your satisfaction?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

7. How satisfied were you with the doctor's diagnosis and treatment recommendations?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

8. If surgery was recommended, did the doctor/technician discuss with you in detail information about the need for surgery and recommended procedure(s)?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

9. If you had surgery, were you satisfied with your post-operative follow-up?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

10. When asking billing/insurance questions, did you find our billing/ insurance personnel:
Friendly and Courteous?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So
Helpful?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

11. Did you find that visiting our office was a positive eye care experience?
does not apply 1 - Not So Much 2 3 - Somewhat 4 5 - Very Much So

12. Would you recommend our eye care practice to your friends?
yes no

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