Patient Satisfaction Survey
Page 1

1.
Which service did you use at Gold Eye Clinic?

2.
How do you rate your satisfaction with the service provided by Gold Eye Clinic and the results?
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Please provide additional information

3.
What was the best part about receiving this service and/or procedure?

4.
What was the worst part about receiving this service and/or procedure?

5.
Who was your doctor at Gold Eye Clinic?

6.
How do you rate your satisfaction with your Gold Eye Clinic doctor?
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Please provide additional information

7.
If you are a LASIK patient, how did you hear about LASIK at Gold Eye Clinic?
Newspaper
Television
Brochures/Video
Website
Patient referral. If so, who?

8.
Why did you choose Gold Eye Clinic?

9.
Did you consider any other practices before choosing us?
Yes
No
If yes, which one?

10.
Overall, how satisfied are you with Gold Eye Clinic?
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Please provide additional information

11.
Is there anything you are disappointed with?

12.
Please explain if we could have done anything better during your consultation.

13.
Please explain if we could have done anything better on your surgery day.

14.
Please explain if we could have done anything better during your post-op care.

15.
Please leave any additional comments about the services and/or care provided to you by your doctor.

16.
Please leave any additional comments about the services and/or care provided to you by our staff.

17.
Anything else you'd like to tell us?

18.
Your name? (Optional)



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