Patient Survey - Eye Elements

Based on your most recent experience, how likely are you to recommend us to a friend or colleague?*
1 - Not at all likely 2 3 4 5 - Extremely likely
How do you rate your experience with our staff in the office during your visit?*
1 - Unsatisfied 2 3 4 5 - Very satisfied
How was your wait time to see the doctor?*
1 - Poor 2 3 4 5 - Excellent
How well did your doctor explain your exam findings?*
1 - Poor 2 3 4 5 - Excellent
How satisfied are you with your doctor?*
1 - Unsatisfied 2 3 4 5 - Very satisfied
How would you rate the staff on assisting you in your frame and/or contact selection?*
1 - Poor 2 3 4 5 - Excellent Does not apply
Overall, how satisfied are you with the selection of eyeglass frames?*
1 - Unsatisfied 2 3 4 5 - Very satisfied Does not apply
Overall, how satisfied are you are with Eye Elements?*
1 - Unsatisfied 2 3 4 5 - Very satisfied
Any other comments? Please let us know what you liked or would improve upon:
Office*
Doctor Name*
How many years since your previous exam?*
How did you hear about us? (Select all that apply.)
- TV
- Radio
- Direct Mail Piece
- Billboard
- Health Fair
- Online Ad
- Social Media
- Web Search
- Other
First Name
Last Name
Email
TFT Dependency

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