Thank you for selecting our office for your yearly comprehensive eye health care. We hope you were totally satisfied with your experience in our office. It is only through your openness that we can improve. Therefore, may we ask that you evaluate your last visit. We will share your comments with each staff member at our next office meeting. Please tell us your experiences in our office, great or not so. The following survey may be filled out online or downloaded and mail the survey to us. You may also fax it to 256.880.1277 or bring it by.

Dr. Coulter and staff.

		Excellent	Good	Fair	Poor	N/A
1	How were your phone calls handled?
2	How was availability of appointments?
3	How was the reception area time?
4	How was the care you received from our technical staff?
5	How was the quality of care you received from the Doctor?
6	How did the Doctor answer any concerns or questions you had?
7	How was the waiting time for your eyeglasses?
8	If you were fit with contact lenses, how would you rate the fitting, follow up care and overall satisfaction with the lenses?
9	How would you rate the overall quality of care you received?
10	The selection of eyeglasses was:	Please Select One Just right Too many of the same type Too many to choose from/too confusing Not enough to choose from
11	Our fees were:	Pleease Select One Much lower than expected Slightly lower than expected Slightly higher than expected Much higher than expected
12	Why did you ORIGINALLY choose our office for your eye health care?
13	Will you return next year for your yearly comprehensive eye health examination?

10	The selection of eyeglasses was:	Please Select One Just right Too many of the same type Too many to choose from/too confusing Not enough to choose from
11	Our fees were:	Pleease Select One Much lower than expected Slightly lower than expected Slightly higher than expected Much higher than expected
12	Why did you ORIGINALLY choose our office for your eye health care?
13	Will you return next year for your yearly comprehensive eye health examination?	Pleease Select One Yes No If you answered no, why not?

What one thing could we have done to make your visit truly exceptional?

Additional comments:

Optional
Your Name
Name of assistant(s) who helped you:
If you gave us your name above, may we call you to further discuss your comments?	Please Select One Yes No