Patient Satisfaction Survey

Quality of Care from Our Staff

Great Good Fair Poor N/A

Quality of Care from Our Doctors

Great Good Fair Poor N/A

Satisfaction with our variety of eyeglass selection

Great Good Fair Poor N/A

Satisfaction with your eyeglass purchase

Extremely Satisfied Satisfied Dissatisfied N/A

Satisfaction with your contact lenses

Extremely Satisfied Satisfied Dissatisfied N/A

Will you return to White Rock Optometry Clinic for your:

eye health (exam) to purchase glasses/contact lenses both neither

What is your overall rating of our office on a scale from 1(poor) to 10 (excellent)?

1 2 3 4 5 6 7 8 9 10

Do you have any suggestions on how we can improve our office? Is there anyone you would like to commend for a job well done? Please let us know!

If you would like our clinic to contact you regarding your survey, please provide us with your name, phone number and/or email.

Wufoo