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Roberts Eyecare Associates Patient Survey
Roberts Eyecare Associates Patient Satisfaction Survey
Please select the examination location.
*
Vestal
Sidney
Location
Vestal
Sidney
Please rate the following categories with 5 stars representing excellent and 1 star poor.
*
Overall Satisfaction
1
2
3
4
5
Thorough Eye Health Examination
1
2
3
4
5
Sufficient Time with the Doctor
1
2
3
4
5
Treated in a Professional Manner
1
2
3
4
5
Office Staff Friendly and Knowledgeable
1
2
3
4
5
Office Appearance
1
2
3
4
5
Office Location
1
2
3
4
5
Office Hours
1
2
3
4
5
Obtained Timely Appointment
1
2
3
4
5
Waiting Time at Office
1
2
3
4
5
Frame and Lens Selection
1
2
3
4
5
Opticians (Adjust GLasses and Staff in Frame Room)
1
2
3
4
5
Yes
No
Would Recommend Practice to Friends and Relatives
*
Describe any particular staff member or service that strongly influenced your visit?
0/255 characters
Is there anything we could do to improve our service to you?
0/255 characters
Additional Comments:
The following information is optional.
First Name
Last Name
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Phone Number
Email Address
Thank you for taking time to fill out this survey. Your responses will help us to provide you with better eye care.
When completed, please click on the SUBMIT button.
Sincerely,
Dr. Roberts
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