THE EYE INSTITUTE – PATIENT SURVEY

Patient Name*

Email *

Date:

1. Efficiency of the check in process and professionalism of staff

Excellent Very Good Good Fair Poor

2. Ease of using our office phone system when contacting us

Excellent Very Good Good Fair Poor

3. Total Wait time (waiting and exam rooms)

0 -15 min 15 - 30 min 30 - 45 min Over 45 min

4. Are you happy with text message reminders for appointments?

YES NO N/A

5. Ease of accessing our website and patient portal

10 9 8 7 6 5 4 3 2 1 N/A

6. Accessibility of handicapped spaces and entry

Excellent Very Good Good Fair Poor N/A

7. Did you receive a prescription for needed medication?

YES NO N/A

8. Were your prescriptions called into your pharmacy in a timely manner?

YES NO N/A

9. Did you receive a prescription for eyeglasses?

Yes No N/A

10. Did you purchase eyeglasses from our optical department?

Yes No

11. If you were here for a routine visit and chose the OPTOS machine in place of being dilated, were you satisfied?

YES NO N/A

12. How would you rate the overall care you received from your provider?

Excellent Very Good Good Fair Poor

13. How likely is it that you would recommend our services to a friend or family member?

10 9 8 7 6 5 4 3 2 1

14. Your age group

Under 20 21 - 35 36 - 50 51 - 65 Over 65

Additional Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

--mi

Address

968 Hamburg Tpke
Wayne, NJ 07470

Contact Information (973) 696-0300