Scott & Christie Eyecare Associates Survey
1.

Please check all services and products that you have utilized as a patient. 

(SCOTT & CHRISTIE EYECARE ASSOCIATES)
Cataract Evaluation/Surgery
Glaucoma Evaluation/Treatment
Diabetic Retinal Exams
Multifocal Lens Implants
Macular Degeneration Evaluation and Treatment
Audiology Evaluation/Hearing Aids
Specialty Vitamins
Dry Eye Evaluation/Treatment
Other  
2.

(GOOD LOOKS EYEWEAR)
Routine Eye Exam
Contact Lenses Purchase
Eyewear Purchase
Sports Eyewear Purchase (golf/cycling/fishing-
)
Specialty Lenses Purchase (progressive/Transiti-
ons/high index)
Prescription Sunglasses Purchase
Non-prescription Sunglasses Purchase
Other  
3.

(INSIGHT LASIK & REFRACTIVE GROUP)
LASIK Surgery
Refractive Procedures
4.

Patient Experience 

Please use the 5-point scale to rate the following:
 Poor Fair Good Very Good Excellent 
Convenience of our office hours
Ease of making your appointment
Helpfulness on the telephone
Promptness in returning your phone calls
Speed of registration process
Comfort and cleanliness of our offices
Help with understanding your insurance coverage
Answering insurance/billing questions
Promptness with which questions or problems were satisfactory resolved
Waiting time in the exam room before being seen
5.

Patient Experience 

Please use the 5-point scale to rate the following:
 Poor Fair Good Very Good Excellent 
Degree to which you were informed about any delays
Explanations provided about your medical/optical problem or condition
Concern shown for your problem/condition
Care provider's efforts to include you in the treatment decisions
Information the care provider gave you about medications
Instructions the care provider gave you about follow-up care
Concern for your privacy
Ease of obtaining test results
Amount of time the care provider spent with you
Your confidence in this care provider
6.

Patient Experience 

Please use the 5-point scale to rate the following:
 Poor Fair Good Very Good Excellent 
Overall friendliness and courtesy of the doctor
Overall friendliness and courtesy of the optician
Overall friendliness and courtesy of the technician
Overall friendliness and courtesy of the receptionist
Overall satisfaction with your visit
Your experience with us compared to other businesses/practices?
Likelihood of you recommending our practice/optical services
7.

How did you learn of our services?
Family/Friend
Office Point-of Sale
Television
Internet
Newspaper
Radio
Our Employees
Other  
8.
Was this your first visit to:Scott & Christie and Associates
Yes
No
9.

Was this your first visit to:

InSight LASIK & Refractive Group
Yes
No
10.

Was this your first visit to:

Good Looks Eyewear
Yes
No
11.

How many years have you been a patient of:

Scott & Christie and Associates
Less than 1
1-2
3-5
6-9
10 plus
12.

How many years have you been a patient of:

InSight LASIK & Refractive Group
Less than 1
1-2
3-5
6-9
10 plus
13.

How many years have you been a patient of:

Good Looks Eyewear
Less than 1
1-2
3-5
6-9
10 plus