Patient Satisfaction Survey

Take a few minutes to fill out this Patient Satisfaction Survey and we will award you with a $10 Family Eye Care Gift Card to use at your next appointment

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

1. How professional and courteous was our staff on the phone?
5	4	3	2	1	N/A
2. Were you able to make an appointment at a convenient time?
5	4	3	2	1	N/A
3. Were you greeted properly when you arrived at the office?
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. Did the Doctor treat you well and answer all your questions during your visit?
5	4	3	2	1	N/A
8. How satisfied were you with the ability of Family Eye Care. to have your glasses or contact lenses ready when promised?
5	4	3	2	1	N/A
9. Would you recommend our practice to your family and friends?
Yes	No
10. 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
11. What did you like best about your office experience?
12. If you have recommendations that could improve the performance of the office, please provide them.
13. Overall, do you believe the time you spent in the office was:
Comprehensive, just what I thought
Too long, could have taken less time
Too short, not enough time taken with my specific needs
14. How did you first hear about Family Eye Care?
Choose One... Radio Yellow Pages Insurance Plan Vision Screening Location of Office Promotional Flyer/Mailer Internet Search Referral from Friend/Family Referral from Employer Television Ad Other
15. If you did not purchase eyewear or contacts from Family Eye Care, 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
If you purchased glasses or contacts elsewhere, please tell us where you made your purchase:
16. Are there any individuals that you would like to recognize for their service?
Information about your visit:
Date of Official Visit:
--- Jan. Feb. Mar. Apr. May Jun. Jul. Aug. Sep. Oct. Nov. Dec.   --- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 --- 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Location Visited:
--- New Kensington Penn Hills North Hills
Purpose of Visit?
Yearly Eye Exam
Blurred Vision / Emergency Visit
Personal Information:
Patient Name:
Your relationship to the patient?
Parent
Spouse
Self
Your Name:
Are you 18 or older?
Yes	No

NEW KENSINGTON ~ 320 Central City Plaza | New Kensington, PA 15068 | 724.335.5721 ~

PENN HILLS ~ 509 Long Road | Pittsburgh, PA 15235 | 412.731.1930 ~

NORTH HILLS ~ 8050 McKnight Road | Pittsburgh PA 15237 | 412.364.4700 ~