Patient Satisfaction Survey
 
                           
 

Thank you for choosing our practice for your vision care. Your satisfaction with the services we provide is important to us. Please complete the short, anonymous survey below to help us provide the best service possible.

  
                           
  1. Convenience of our office hours Excellent Very Good Good Fair Poor  
  2. Ease of making your appointment Excellent Very Good Good Fair Poor  
  3. Promptness with which you were seen by the doctor Excellent Very Good Good Fair Poor  
  4. Thoroughness of care you received Excellent Very Good Good Fair Poor  
  5. Clarity of Doctor's explanations Excellent Very Good Good Fair Poor  
  6. Doctor's friendliness and courtesy Excellent Very Good Good Fair Poor  
  7. Staff's friendliness and courtesy Excellent Very Good Good Fair Poor  
  8. Help with understanding your insurance coverage (if applicable) Excellent Very Good Good Fair Poor  
  9. Selection of eyeglass frames Excellent Very Good Good Fair Poor  
  10. Knowledge/assistance of optical staff Excellent Very Good Good Fair Poor  
  11. Comfort and cleanliness of office Excellent Very Good Good Fair Poor  
  12. Overall satisfaction with your visit Excellent Very Good Good Fair Poor  
  13. Will you be returning to see us? Yes No Uncertain      
  14. Would you recommend us to others? Yes No Uncertain      
 
How can we improve? Please enter any comments or suggestions below:
 
What is your name?    (Optional, but it helps us provide better service)
 
The doctor's name?    (If you saw the doctor)
 
 
 
     
 
  Jonathan Smithee, O.D. 
  P.O. Box 1418
Placerville, CA 95667

530-672-2892