[ Appointment Date ] Select One January February March April May June July August September October November December Select One 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select One 2007 2008 2009

[ Office ] Select One 79 Crossing-St. Peters 94 Crossing 141 & Olive Arnold Ballwin Belleville Bogey Hills Brentwood Pointe Chesterfield Chesterfield Valley Columbia Creve Coeur Edwardsville Ellisville Eureka Fairview Heights Fenton Festus Florissant Florissant-Dunn Florissant-Hwy. 67 Harvester High Ridge House Springs Kirkwood Maplewood Mid Rivers O'Fallon North O'Fallon South Pacific Rock Hill Shiloh South County Town & Country Town & Country-Mason Town & Country Crossing Troy Union Warrenton Washington Webster Groves Wildwood Wentzville

[ Optician ]

[ Doctor ]

1.] Are you completely satisfied with Clarkson Eyecare?

Yes No

Yes No

3.] Was your initial call to make an appointment completely satisfactory?

Yes No

4.] Were you greeted promptly and with enthusiasm when you arrived at the office?

Yes No

5.] Did the doctor exceed your expectations during your visit?

Yes No

6.] Were you completely satisfied with the frame selection?

Yes No

7.] Were you completely satisfied with the explanation of lenses and lens options?

Yes No

8.] Were you completely satisfied with the contact lens options?

Yes No

9.] If you answered NO to any of the above questions, please let us know what we can do to improve your Clarkson Eyecare experience:

Today's Date January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008 2009

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