Only Type your First Name and Last Initial (Ex. John D.)

Your Name:
Your City:
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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

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Telephone communications
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Office comfort & cleanliness
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Waiting time in the office
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Receptionist skills
(professionalism/politeness)
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Eye Technician skills
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Doctor skills
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Reason for visit addressed
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Amount of time spent with Doctor
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Overall visit rating
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Any further positive or negative comments you would like to add in the space below would be much appreciated

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