Patient Survey

Name:

Email:

Examing Doctor:

Thomas Ballard, O.D.  Lori Bourque, O.D.

Did the staff greet you politely?
Yes No I dont recall

Did you have to wait over 15 minutes past your appointment tome for your preliminary testing to begin? If so, how long?
No    20-30 minutes           30-45 minutes           over 45 minutes

Did the doctor give you a full explanation of your visual condition and recommendation for a correction?
Yes    Not really       I don’t recall

Were you happy with the selection of frames in our optical?
Yes    Not really       I didn’t look

How would you rate your overall visit?
Excellent       Very Good   Average        Poor

Would you refer your friends and to us?
Yes   No    I’m not sure