Patient Satisfaction Survey - Eyeworks of Millis

Wait Time*

5 - Extremely Satisfied
4 - Satisfied
3 - Neutral
2 - Dissatisfied
1 - Extremely Dissatisfied
0 - Not Applicable

Office Appearance*

Office Staff

Name of Front Staff Personnel

First Last

Doctor*

Name of Your Doctor

First Last

Contact Lens Technician

Name of Your Contact Lens Technician

First Last

Optician*

Name of Your Optician

First Last

Eyewear Selection*

Overall Experience*

We appreciate any comments or testimonials

Do we have permission to use your feedback as a testimonial for marketing purposes?*

Yes
No

Thank you for completing this survey

If you would like to remain anonymous, you do not have to fill out the below information. If you provide the below information, our office would greatly appreciate it.

Name

First Last

Email

Address

Street Address Address Line 2 City ZIP Code