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. There is a limit of three (3) Patient Satisfaction Survey $10 gift certificates per household per year. Please allow 4-6 weeks for receipt of your gift certificate.
Please take a few moments and let us know what you thought of your last visit...
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 experience 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 would not return
N/A - Not Applicable
Note: All fields are required unless marked with *
Date of Your Office Visit
Please insert the Doctor's name you visited with.
Purpose of Visit
1) How professional was our staff on the phone?
5 4 3 2 1 NA
2) During your visit, how well were your specific needs meet?
3) How well were you educated on the vision tests and exam you received during your visit?
4) How well would you rate the value of services you received while at CLI?
5) How professional and courteous was our staff during your visit to CLI?
6) How long did you have to wait to be seen by the Doctor?
7) What was the quality of care you received from the Doctor?
8)How well did we follow up with you once you ordered contacts and/or glasses?
9)Would you recommend our practice to family and friends?
Yes No
10) If you are a new patient, were you aware that you could submit your introductory paperwork online and order contacts and other products online?
11) What did you like best about your experience at CLI?
12) What recommendations do you have so we can improve our patient care experience?
13) 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.
14) How did you first hear about Contact Lens Institute?TelevisionPromotional Flyer/Mailer
RadioInternet Search
Yellow PagesReferral from Friend/Family
NewspaperReferral from Employer
Insurance Plan Book/WebsiteBuilding Sign
Vision ScreeningOther (Please Explain Below)
15) If you purchased eyewear somewhere other than Images Optical Boutique, which of the following best describes the reason why you chose not to purchase from us. (Check all that apply):ServicePrice
SelectionDidn't want new glasses this year
Other (Please explain below)
Also, please tell us where you made your purchase:
16) If you purchased contacts somewhere other than CLI, which of the following best describes the reason why you chose not to purchase from us. (Check all that apply):ServicePrice
SelectionOther (Please explain below)
17) Are there any individuals you would like to recognize for their service?
18) Would you like for us to contact you with regards to a specific issue? Yes NoIf yes, please fill out this information here.
19) Do you plan on returning for your next comprehensive eye examination?
20) Are other Medical Providers providing you with Online services?
Enter Comments Below:*
E-Mail: Not Necessary unless you want to be contacted.
