Wufoo

Was this your first visit to our office as a patient?
Yes No
Which doctor were you seen by?
Dr. Richard Wiscount Dr. Lani Siddique None - Eyeglass purchase only

Please evaluate your experience in our office.
	Excellent	Very Good	Good	Fair	Poor
Ease of making an appointment	1	2	3	4	5
Made to feel welcome in our office	1	2	3	4	5
Comfort and cleanliness of the office	1	2	3	4	5
Taken care of in a timely manner	1	2	3	4	5
Time spent with you by the doctor	1	2	3	4	5
Quality and thoroughness of the care you received from the doctor	1	2	3	4	5
Quality of the care you received from the staff	1	2	3	4	5
Explanation you received of fees and insurance coverage	1	2	3	4	5
Questions answered by doctor and staff to your satisfaction	1	2	3	4	5
Overall satisfaction with your office experience	1	2	3	4	5

If you purchased eyeglasses, please evaluate your experience.
	Excellent	Very Good	Good	Fair	Poor
Helpfulness of opticians in selecting your eyewear	1	2	3	4	5
Quallity and quantitiy of eyeglass frame selection	1	2	3	4	5
Eyeglass options and fees were explained to you satisfactorily	1	2	3	4	5
Amount of time it took until you received your glasses	1	2	3	4	5
Satisfaction with the eyewear you purchased	1	2	3	4	5
Overall satisfaction with your eyewear purchase experience	1	2	3	4	5

Is there any aspect of your visit to our office that can use some improvement?
Was there any aspect to your visit that was particularly noteworthy or exceptional?
Any additional comments or suggestions:


	Definitely will	Probably will	Probably will not	Definitely will not	Not Sure
How likely is it that you will choose our office for your next eye examination or eyewear purchase?	1	2	3	4	5
How likely is it that you would refer a family or friend to our office for eye care?	1	2	3	4	5

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