Blaine Eye Clinic

Feedback

Get your $10 gift card for Blaine Eye Clinic by doing this short survey. We are continually doing our best to serve each of our patients in the manner he or she deserves. We strive to not only meet your vision needs, but actually surpass them. We appreciate your input and would like to thank you by offering you a $10 gift card for completing this survey. Thank you so much for taking time to help us help you.

You must be 18 years or older to complete this survey and receive your gift card. Limit one $10.00 Gift Certificate per person, per year

Instructions

Rate the following questions using the scale below:

• 5 - Exceeded my expectations for a doctors visit
• 4 - Better than most experiences in other eye clinics
• 3 - About the same as other eye clinics I have visited
• 2 - Worse than other eye clinics I have visited
• 1 - I would not return
• N/A - Not Applicable

Please Provide Feedback:

1. *How professional and courteous was our staff on the telephone?
   1 2 3 4 5 N/A
2. *During your office visit, how well did we listen to your specific needs?
   1 2 3 4 5 N/A
3. *How well were you educated on the vision tests and examinations you received?
   1 2 3 4 5 N/A
4. *How courteous and professional was our staff during every aspect of your visit?
   1 2 3 4 5 N/A
5. *How well did we follow up with you if you ordered contacts or glasses?
   1 2 3 4 5 N/A
6. *If you ordered glasses, how was your experience?
   1 2 3 4 5 N/A
7. *If you ordered contact lenses, how was your experience?
   1 2 3 4 5 N/A
8. *How would you rate the values of the services and product received?
   1 2 3 4 5 N/A
9. *What aspect of your experience with our office was the best?
10. *What recommendations do you have that could help us better serve you?
11. *Overall, do you believe the time you spent in our office was
    Thorough, more than I expected.
    Thorough, as I expected.
    Too long, could have taken less time.
    Too short, not enough time was spent helping me.
12. If you purchased glasses or contact lenses somewhere other than the Blaine Eye Clinic, which of these reasons best describes why you chose not to purchase from us (check all that apply):
    Service
    Price
    Selection
    Didn't want new glasses this year
    Other (specify below)
    
13. *Which individuals would you like to recognize for service?
14. *Date of Your Office Visit:
    Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2009 2010
15. *Doctor:
    Lynn A. Sulerud, OD Georgiann Jensen, OD Ryan Fedor, OD Breann Forliti, OD
16. Enter any additional comments below:
17.  
    Submit Feedback
18.  * denotes required field