Date: *

First Name:

Last Name:

Address:

Doctor:

Optician:

Is it permissible to publish your survey? Yes No

Thank you for taking the time to answer a few questions:

Please grade A-E  Excellent to Poor:   A: Excellent  C-Average   E-Poor

First Impression: A B C D E

Eye Examination A B C D E

Frame Selection A B C D E

Fitting and Adjustment A B C D E

Value for the Dollar A B C D E

Friendly Courteous Personnel A B C D E

Overall Satisfaction A B C D E

Personal Comments (200 chars left)

What did you like best about your eyecare experience?

What changes would have made your eyecare experience better?