Dear Patient,

We want to thank you for giving us the opportunity to serve you. Please help us enhance the experience of your next visit by taking a couple of minutes to tell us about the service you received at your most recent appointment. We appreciate your business and want to make sure your experience at Clarkson Eyecare is always positive.

Sincerely,

Bill Jehling, President - Clarkson Eyecare
phone: 636.227.2600 ext. 2001


[ Appointment Date ]

Please rate your experience at Clarkson Eyecare based on the following scale:

[ 5-Excellent 4-Good 3-Satisfactory 2-Less than Satisfactory 1-Poor NA-Not Applicable ]

 

1.] The treatment you received when you called to set up your appointment.


Good




2.] The time between when you scheduled your appointment and the appointment date.


Good




3.] The greeting you received when you arrived at the office for your appointment.


Good


• Poor

4.] The time you waited to see the doctor.


Good


• Poor

5.] The overall appearance of the office.


Good


• Poor

6.] The explanation and recommendations from your doctor concerning you eye health.


Good


• Poor

7.] The selection and explanation of features and options available in lenses and frames.


Good


• Poor

8.] The selection and explanation of features and options available in contact lenses.


Good


• Poor

9.] The choices available in frames and contacts.


Good


• Poor

10.] The fee charged for the item(s) and service(s) you received.


Good


• Poor

11.] Your overall experience at Clarkson Eyecare.


Good


• Poor

12.] Would you recommend Clarkson Eyecare to a family member or friend?



13.] How did you hear about Clarkson Eyecare?









14.] Please provide additional comments and/or a
testimonial about your experience at Clarkson Eyecare.

Today's Date

Name

Address

City State Zip

Phone

Email

 

family coupons
glasses
contacts
LASIK


I consent to the use of my name and this text for advertising and promotional purposes in connection to my experience with Clarkson Eyecare without additional compensation.