Patient Survey

Your opinion matters, Thank You for your time.

Appointment Date:
Optician Name:
Examined by Doctor:	Dr. Davis Dr. Salyer
Was your initial call to make an appointment satisfactory?	Yes No
Were you greeted promptly and with enthusiasm?	Yes No
Were you satisfied with the promptness with which you were seen by the doctor?	Yes No
Was the office clean and the atmosphere comfortable?	Yes No
Do you feel that the pre-test technician was professional and competent?	Yes No
Did the doctor meet your expectations by providing quality care?	Yes No
Were you satisfied with our frame selection?	Yes No
Were you satisfied with the explanation of lenses and lens options?	Yes No
Were you satisfied with Procare Vision Center?	Yes No
Would you refer a friend or family member to Procare Vision Center?	Yes No
If you answered NO to any of the above questions please let us know how we can improve.
Were there any staff members who gave you service above and beyond what you expected?
Additional Comments.
Today’s Date
Name(optional)
I consent to the use of my name and this text for advertising and promotional purposes in connection to my most recent visit to Procare Vision Center without additional compensation. If no name is given the provided comments may be used for advertising or promotional purposes.