Coley and Coley Family Eye Care | Murfreesboro

Patient Satisfaction Survey
Please take a few moments to answer some questions so we may provide the highest level of service to our patients.

Personal
Was this your first visit?	Yes			No
Day of your appointment
	M	Tu	W	Th	F	S

General

Very Good

Good

Fair

Poor

Very Poor

N/A

1.

Convenience of Scheduling

2.

Convenience of office hours

3.

Comfort and cleanliness of office

4.

Waiting time to see the doctor

Front Office Staff

Very Good

Good

Fair

Poor

Very Poor

N/A

1.

Phone calls handled promptly and courteously

2.

Assistance with insurance companies

3.

Ease of arranging follow-up visits

4.

Explanation of fees at time of check out

Doctor

Very Good

Good

Fair

Poor

Very Poor

N/A

1.

Thoroughness of the exam

2.

Quality of time spent with doctor

3.

Explanations given were clear

4.

Confidence you have in the doctor

If you received glasses or contact lenses

Very Good

Good

Fair

Poor

Very Poor

N/A

1.

Knowledge of staff

2.

Courtesy and friendliness of staff

3.

Selection and variety of glasses

4.

Selection and variety of contacts

Overall Impressions

Very Good

Good

Fair

Poor

Very Poor

N/A

1.

Overall quality of services

2.

Value received of exam

3.

Value received of glasses/contacts

On a scale of 1 to 10, what is the likelihood that you ill refer a family member or friend to Coley and Coley Family Eye Care?

Comments/Suggestions/Recommendations/New Frame Lines

Examining Doctor:

Name (Optional)

Date: 9/05/10