Patient Questionnaire

Patient Feedback Survey - your chance to tell us what we're doing right as well as wrong!

We welcome the opportunity for you to give us your feedback about your experience with us. If you have recently had a test, please complete the below form as fully as possible. We appreciate you taking your time to do this to make us look after you better.

Your Name

Practice / Visit Details

Practice Attended Optometrist (if known) Dispensing Optician (if known)

Examination Feedback

How were you treated by

Practice Staff Excellent Very Good Good Poor

Optometrist/Contact Lens Optician Excellent Very Good Good Poor

Dispensing Staff Excellent Very Good Good Poor

During the eye examination did the optometrist (tick all that apply) Explain what was happening Give clear explanation of outcome Explained in easy to understand_terms

Were you satisfied with the eye test? Excellent Very Good Good Poor

What did you think of our frame range? Very Satisfied Fairly Satisfied Fairly Dissatisfied Completely Dissatisfied

Comments

Do you have any thoughts on how we might improve our service or frame range? If you would like to be contacted please enter your name, address, email address and telephone number here : Any other comments?

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