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Bennett S. Romanoff, MD
Chief of Ophthalmology
Flower Hospital
Flower Hospital Medical Office Building
5300 Harroun Road Ste 112
Sylvania, OH 43560
419-885-5556
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Please invest a few moments to rate our people and procedures. This feedback enables us to continue to improve.
There are 10 questions like the one below.
Patient Survey
id
date time
1. When you received your prescription for glasses or contacts, how satisfied were you with the doctor or staff member’s explanation about our optical services?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 2
2. How acceptable was the amount of waiting time before seeing one of our optical staff members?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 3
3. How would you rate the overall service of the optician?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Friendly and courteous?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Competent and professional?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 4
4. How would you rate the optician’s ability to communicate knowledge to you about optical products?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 5
5. How satisfied were you with the selection of frames that were available?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 6
6. How would you rate the timeliness of delivery for your glasses?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 7
7. How would you rate the quality of the glasses you received?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Frames?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Lenses?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
Survey Page 8
8. Please rate your overall experience with our optical dispensary
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
N/A
Survey Page 9
9. Would you recommend our optical dispensary to your friends?
Fell far short of my expectations
Partially met my expectations
Met my expectations
Exceeded my expectations
Greatly exceeded my expectations
N/A
Survey Page 10
10. Please provide any additional comments and your name (optional)