4200 County Road 42 W  • Savage

952.895.5434

19645 Pilot Knob Road #106 • Farmington

651.463.2020
         
Thank you for choosing the Family Vision Clinic for your eye care.  Your satisfaction with our services and products is important.  Please complete the following short survey and let us know how to further enhance your experience.  We value all feedback you can provide; be it positive or negative.  All information is strictly confidential. 

 

Services:

 

1) How would you rate the ability to get a convenient appointment?
        Excellent        Very Good        Good        Fair        Poor     

   

2) Which night of the week do you prefer for evening hours?

         Tuesday        Wednesday        Thursday        No preference

 

3) How did you hear about us?

         Yellow Pages       Insurance      Newspaper Ad       Friend/Acquaintance      Other

 

4) Upon arrival, how would you rate the friendliness and prompt attention by the staff?

        Excellent        Very Good        Good        Fair        Poor 

 

5) How would you rate the explanation of cost and insurance coverage?
        Excellent        Very Good        Good        Fair        Poor  

 

6) How would you rate the doctor's willingness to listen to your concerns/questions?
        Excellent        Very Good        Good        Fair        Poor     

 

7) How would you rate the doctor's explanation of the test results and the condition of your eyes?
        Excellent        Very Good        Good        Fair        Poor     

 

 

Eyewear - (if you did not browse or purchase eye wear, please skip to question 11)

 

8) How would you rate the expertise of the technical staff?
        Excellent        Very Good        Good        Fair        Poor     

 

9) How would you rate the selection of eyewear?
        Excellent        Very Good        Good        Fair        Poor     

 

10) How would you rate your overall satisfaction with your eye wear?
        Excellent        Very Good        Good        Fair        Poor     

 

 

Contact Lenses - (if you were not fitted or did not purchase contact lenses please skip to question 14)

 

11) How would you rate the contact lens fitting process?
        Excellent        Very Good        Good        Fair        Poor     

 

12) Did you purchase contact lenses from us?
                    Yes      No

 

13) If you purchased contact lenses elsewhere, what was the main reason?
         Convenience        Price        Both

 

 

Overall

 

14) How would you rate your overall satisfaction with the Family Vision Clinic?
        Excellent        Very Good        Good        Fair        Poor     

 

15) Based on your experience, will you return to the Family Vision Clinic for your future eye care?
                     Yes      No

 

16) Based on your experience, would you recommend friends and/or family to the Family Vision Clinic?
                     Yes      No

 

17) Do you have any recommendations or general comments that could improve the performance of our office?

 

Please provide the following contact information so we can contact you for any questions/concerns.  All information is kept strictly confidential.

First Name
Last Name
Home Phone
E-mail

Check here if you like to be contacted for any specific questions or concerns:

           

 

                           

 
Questions?  Send mail to info@fvc2020.com or use our Feedback form. 
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