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Patient Feedback Form

Rx Optical is committed to providing excellent care to our patients. We want you to tell us about your experience as a patient. Please take a few minutes to complete the following feedback form so that we may continuously monitor and evaluate our patients’ perception of our care and services.

The information you provide is for research purposes only. It is confidential and will not be shared with others or for marketing.

Be sure to enter your 6 digit invoice number to recieve your $10.00 coupon.

1. Did you have an eye examination? (If no go to question 3.)
      YesNo

2. The length of time spent waiting to be seen by the Doctor was:
ExcellentVery GoodSatisfactory
Below AveragePoor

3. The explanation of your vision options in understandable terms were:
ExcellentVery GoodSatisfactory
Below AveragePoor

4. The office environment, its cleanliness, comfort, lighting, temperature, etc., was:
ExcellentVery GoodSatisfactory
Below AveragePoor

5. The availability of educational and informational materials regarding your vision was:
ExcellentVery GoodSatisfactory
Below AveragePoor

6. Our staff’s knowledge of your insurance coverage was:
ExcellentVery GoodSatisfactory
Below AveragePoor

7. Our selection of frame and lens options were:
ExcellentVery GoodSatisfactory
Below AveragePoor

8. The promptness of receiving your glasses or contact lens order was:
ExcellentVery GoodSatisfactory
Below AveragePoor

9. Your overall experience at Rx Optical was:
ExcellentVery GoodSatisfactory
Below AveragePoor

10. Would you recommend Rx Optical to others?
      YesNo

11. If NO, why not?
     

12. What suggestions do you have that might help us serve you better?
     

13. Enter the invoice number on your receipt here to receive your $10.00 Coupon:
     

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