Patient Satisfaction Survey

Dear Enrollee:
I wish to thank you for selecting Sterling VisionCare as your eye care provider. We are continually evaluating and improving our services and rely on our enrollees to give us constructive feed-back pertaining to their eye examination experience.

We would appreciate it if you would complete the questionnaire below.

Your comments will make a difference.
Thank you.
Nicholas Shashati, O.D President

(PLEASE NOTE: This questionnaire is for your eye examination only. If you have a comment on your eyeglasses or contact lenses and would like to be contacted, please check this box. )

Your Name
Phone
Email
Office That Was Visited

Question	Very Satisfied	Somewhat Satisfied	Somewhat Dissatisfied	Very Dissatisfied
Was the office and examination area clean and neat?
Was the staff efficient and cooperative?
Did the doctor appear and act professional?
Did the doctor explain the various tests as he/she did them?
Was the prescription satisfactory for your needs?
Did you feel the price of the enrollment and eye examination was fair?
Would you use the services of Sterling VisionCare again?

COMMENTS:

Sterling VisionCare is a registered trademark of Emerging Vision, Inc.