Survey Zone

Our goal is to provide you with an exceptional experience when you visit Eye Care Associates. That mission is accomplished through a team effort of many individuals who are committed to your total satisfaction.

Get Your $10 Gift Certificate

Your input is very important to us. Participate in our Patient Satisfaction Survey and we'll mail you a $10 gift certificate that can be used for any future purchase with any insurance benefit or promotional discount. You can even give it to a friend or family member for them to use. Please note that $10 gift certificates may not be used for current balances or previous purchases.

We respect your privacy, therefore your personal information is never shared with parties outside of Eye Care Associates. However, we may contact you if you have an issue you would like resolved. We use survey information internally to improve our patient care practices and develop a patient-focused environment for you and your family. Please take a moment to let us know how we are doing.

Instructions

You must be 18 years or older to complete our survey.
Please rate the following questions using the rating scale below:

5 One of the best experiences I've had in a Doctor's office
4 Better than most experiences in other offices
3 About the same as other offices I've visited
2 Worse than in other offices I've visited
1 I wouldn't return
N/A Not Applicable

Note:  All fields are required unless marked with *.

Patient Satisfaction Survey

1) How professional and courteous was our staff on the phone?
5 4 3 2 1 N/A
 
2) During your office visit, how well did we listen to your specific needs?
5 4 3 2 1 N/A
 
3) How well were you educated on the vision tests and exams you received?
5 4 3 2 1 N/A
 
4) How would you rate the value of the services and products you received?
5 4 3 2 1 N/A
 
5) How courteous and professional was our staff during every aspect of your visit? 
5 4 3 2 1 N/A
 
6) How well did we follow up with you if you ordered contacts or glasses?  
5 4 3 2 1 N/A
7) Would you recommend our practice to your family and friends?
Yes No
 
8) If you are a new patient, were you made aware that you can download patient forms at home from our Website in order to reduce your time spent in the office?
Yes No I'm already an Eye Care Associates patient
9) What did you like best about your experience in our office?
 
10) Do you have any recommendations that could improve the performance of our office?
11) Overall, do you believe the time you spent in our office was (check one):
  Comprehensive, just what I thought.
  Too long, could have taken less time.
  Too short, not enough time taken with my specific needs.
  
12) How did you first hear about Eye Care Associates?
  Television Promotional Flyer/Mailer
  Radio Internet Search
  Yellow Pages Referral from Friend/Family
  Newspaper Referral from Employer
  Insurance Plan Book/Website Window Sign
  Vision Screening Other
  Location of Office
 
13) If you purchased eyewear somewhere other than Eye Care Associates, which of the following best describes the reason why you chose not to purchase from us (check all that apply):
  Service Price
  Selection Didn't want new glasses this year
  Other (Please explain below)
 
  Also, please tell us where you made your purchase:
 
 
14) If you purchased contacts somewhere other than Eye Care Associates, which of the following best describes the reason why you chose not to purchase from us (check all that apply):
  Service Price
  Selection Didn't want new contacts this year
  Other (Please explain below)
 
  Also, please tell us where you made your purchase:
 
  
15) Are there any individuals that you would like to recognize for their service?
 
16) Would you like for us to contact you in regards to a specific issue?  
Yes No
Date of Your Office Visit
 
 
Doctor Office Location
 
Purpose of Visit
 
Enter Comments Below:*
Patient Name: 
Relationship to Patient: 
Your First Name: 
Your Last Name:
Are you 18 or older? Yes  No
   
Address:

  
Home Phone: () -
Work Phone: () -  Ext:*
Best Time To Call:
E-Mail:
Mobile/Other:*