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.

New Patient Satisfaction Survey

This survey is for NEW patients only. If this was NOT your first exam at Eye Care Associates, please complete our Previous Patient Survey Form.

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.

Please note that $10 gift certificates MAY NOT be used for current balances or previous purchases. There is a limit of three (3) Patient Satisfaction Survey $10 gift certificates per household per year. Please only complete one survey for each office visit. Please allow 4-6 weeks for receipt of your gift certificate.

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 use the following Rating Scale (where applicable) when responding to this Survey:

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 *. If you are rushed for time, please complete the survey at a time that is more convenient for you. For security purposes, this survey is not linked to your patient records. Therefore, you must complete your complete name and address information in order for us to send you your $10 Gift Certificate.

Patient Satisfaction Survey

1) How did you first schedule your appointment?
  Web Site - I requested appointment on-line and Eye Care Associates confirmed my appointment by telephone
  Telephone - I called to schedule an appointment by telephone
  Walk-in - I stopped by your office and scheduled my exam there
 
2) During the appointment scheduling process, how professional and courteous was our staff on the phone or in person?
5 4 3 2 1 N/A
 
3) 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 N/A - I scheduled the appointment at the office
 
4) Did you use the forms on the Web site prior to your first exam?
Yes No N/A - I scheduled the appointment at the office
 
5) During any telephone interactions you had before or after your exam, how would you rate our ability to address your questions, concerns or needs?
5 4 3 2 1 N/A
 
6) Overall, how would you rate your experience with Eye Care Associates on the telephone?
5 4 3 2 1 N/A
 
7) During your office visit, how well did we listen to your specific needs?
5 4 3 2 1 N/A
 
8) How well were you educated on the vision tests and exams you received?
5 4 3 2 1 N/A
 
9) How would you rate the value of the services and products you received?
5 4 3 2 1 N/A
 
10) How courteous and professional was our staff during every aspect of your visit?
5 4 3 2 1 N/A
 
11) How well did we follow up with you if you ordered contacts or glasses?
5 4 3 2 1 N/A
12) Would you recommend our practice to your family and friends?
Yes No
 
13) What did you like best about your experience in our office?
 
14) Do you have any recommendations that could improve the performance of our office?
15) Overall, do you believe the time you spent in our office was (check one):
  Comprehensive, just what I thought it should be.
  Too long, could have taken less time.
  Too short, not enough time taken with my specific needs.
  
16) How did you first hear about Eye Care Associates?
  Television Promotional Flyer/Direct Mail Piece
  Radio Internet Search
  Yellow Pages Referral from a Friend or Family Member
  Referral from Employer Insurance Website/Plan Book
  Window Sign/Drove By Vision Screening
  News Story Other
 
17) If you did not purchase your eyewear from 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)
  		N/A - I bought glasses from Eye Care Associates
  Also, please tell us where you made your purchase:
 
 
18) 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)
  		N/A - I bought contacts from Eye Care Associates
  Also, please tell us where you made your purchase:
 
  
19) Are there any individuals that you would like to recognize for their service?
 
20) Would you like for us to contact you in regard to a specific issue?
Yes No
21) Who was the optical consultant who helped you today? (the person who helped you select your glasses)

22) Please rate the experience with your optical consultant using the same rating scale used previously:

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

 
22a) Quality of Service
5 4 3 2 1 N/A
 
22b) Satisfaction
5 4 3 2 1 N/A
 
22c) Helpfulness
5 4 3 2 1 N/A
 
22d) Responsiveness
5 4 3 2 1 N/A
 
22e) Friendliness 
5 4 3 2 1 N/A
 
23) How would you rate the overall experience with your DOCTOR during your exam?
5 4 3 2 1 N/A
 
24) Are there any recommendations you would make to help your doctor improve the exam experience?
 
Date of Your Office Visit
 
 
Doctor Office Location
 
Purpose of Visit
 
Enter Comments Below:*

Note:  For security purposes, this survey is not linked to your patient records. Therefore, you must complete your complete name and address information in order for us to send you your $10 Gift Certificate.
Patient Name: 
Relationship to Patient: 
Your First Name: 
Your Last Name:
Are you 18 or older? Yes  No
   
Address:
City:
ST Zip:

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