Dear Patient:

Thank you for visiting our office recently. As part of our commitment to providing excellent care we are continually evaluating the quality of service our patients receive from us.  We would appreciate it if you would take a few minutes to answer the following questions.  Your answers will remain anonymous, so please feel free to give us your honest opinion so that we can best improve our service to you.

Please select the reason(s) for your visit below

First visit with Dr. Hillson	Follow-up visit with Dr. Hillson	AMD Assessment
Cataract Assessment	Glaucoma Assessment	Other Reason for Visit

Please rate each feature of your visit on the scale below

Wait time to get appointment	Poor	Fair	Good	Very Good	Excellent
Telephone communications	Poor	Fair	Good	Very Good	Excellent
Office comfort & cleanliness	Poor	Fair	Good	Very Good	Excellent
Waiting time in the office	Poor	Fair	Good	Very Good	Excellent
Receptionist skills (professionalism/politeness)	Poor	Fair	Good	Very Good	Excellent
Eye Technician skills (professionalism/politeness)	Poor	Fair	Good	Very Good	Excellent
Doctor skills (professionalism/politeness)	Poor	Fair	Good	Very Good	Excellent
Reason for visit addressed	Poor	Fair	Good	Very Good	Excellent
Amount of time spent with Doctor	Poor	Fair	Good	Very Good	Excellent
Overall visit rating	Poor	Fair	Good	Very Good	Excellent

Any further positive or negative comments you would like to add in the space below would be much appreciated

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THANK YOU FOR HELPING US PROVIDE THE BEST POSSIBLE SERVICE TO YOU