Your Name:

Your Address:

Your Age: (optional)

Your Home Telephone Number (optional):

Your Email Address:

Your Website Address:

Are you currently a patient of TotalVision Eyecare Center?
Yes No

How did you find out about TotalVision Eyecare Center on the Internet?
Search Engine
Via the TotalVision Eyecare Center office
A friend told me
From a link
Other

What did you like most about the internet site?

What do you think we can improve?

Would you be interested in purchasing your eyewear/supplies from TotalVision Eyecare Center on the internet via a secure server?
Yes
No
Maybe

This next section is for current TotalVision Eyecare Center patients

How long have you been a patient of TotalVision Eyecare Center?

Is our location convenient for you?
Yes
No

Do you find our waiting room comfortable?
Yes
No

What changes would you make in the physical appearance of our office?

Do you find the TotalVision Eyecare Center staff to be friendly and courteous?
Yes
No
Sometimes
Don't Know

Are your phone calls handled in a prompt courteous manner?
Yes
No
Sometimes
Don't Know

Do you feel our payment and billing policies offer you flexibility?
Yes
No
Sometimes
Don't Know

Do you feel that the doctor tells you enough information about your medical condition?
Yes
No
Sometimes
Don't Know
Comments:

Do you feel that the doctor spends enough time with you?
Yes
No
Sometimes
Don't Know

Is there enough literature(booklets, pamphlets, brochures)available to you from TotalVision Eyecare?
Yes
No
Sometimes
Don't Know

Do you have trouble reaching us after hours?
Yes
No
Sometimes
Don't Know

Is our answering service prompt and courteous?
Yes
No
Sometimes
Don't Know

Are our office hours convenient for you? If no, how could we arrange our hours best to serve you?
Yes
No
Comments:

Please use this area to add any additional comments that you feel would be beneficial to us in serving you better:

We want to thank you for your time and for completing our survey.