Satisfaction Survey

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Satisfaction Survey

Please take a few moments and let us know what you thought of your last visit...

Provider
Doctor
Service Ratings
	Great	Good	Fair	Poor	N/A
Communication prior to appointment
Appointment availability
Waiting room time
Fees
Quality of care from staff
Quality of care from doctor
Concerns or questions answered
Overall quality of care
Scheduling
Preferred day for appointments
Preferred time for appointments
Do you plan on returning for your next comprehensive examination?	Yes No
For no, please tell us why not
Would you schedule appointments online?	Yes No
Products
	Great	Good	Fair	Poor	N/A
Satisfaction with eyeglasses
Satisfaction with contact lenses
Range of eyeglasses selection
Identification (Optional)
Why did you choose us for your eye health care?
Your name (optional)
Additional comments

Costa Mesa Optometry