"*" indicates required fields Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.First Name*Last Name*Phone*Email* Consent I Consent to Receive SMS Notifications, Alerts & Occasional Marketing Communication from company. Message frequency varies. Message & data rates may apply. Text HELP to (856) 997-2593 for assistance. You can reply STOP to unsubscribe at any time. Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Section 1: Your Experience with Us1. How would you rate your overall experience at Premier Eye Associates?* Excellent Good Fair Poor 2. How would you rate the ease of scheduling an appointment?* Excellent Good Fair Poor 3. How would you rate the ease of contacting a team member (phone, email, or in person)?* Excellent Good Fair Poor 4. How would you rate your wait time at our office?* Very Short Acceptable Too Long 5. How would you rate the total time spent at your appointment?* Very Efficient Reasonable Too Long Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Section 2: What You Love6. What do you think Premier Eye Associates does best?* Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Section 3: How We Can Improve8. What do you think we could do better?*9. Have you had any positive experiences at other healthcare practices that we could learn from?*10. What’s something a business has done that really impressed you from a customer service standpoint?* Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Section 4: Services & Technology12. Would you be interested in Premier Eye Associates bringing in any of the following specialties or technology? (Select all that apply)* Binocular Vision Dysfunction (BVD) treatments (for dizziness, headaches, balance, anxiety) Hearing care / audiologist services Nuance hearing aid glasses Meta Smart Frames Virtual Eyeglass Try-on from home Early detection screening devices for glaucoma, diabetic retinopathy, macular degeneration Optilift Technology (non-surgical dry eye treatment and lid lift) None of the above Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Section 5: Eyewear Preferences13. What is most important to you when choosing a frame? (Select up to 2)*Select up to 2 choices. Quality Price point Eco-friendly/Sustainable Brand recognition Story behind the frame Philanthropic mission of the brand 14. Are there any specific frame brands you’d like to see us carry?*15. What is most important to you when choosing lenses? (Select up to 2)*Select up to 2 choices. Quality of vision Warranty / durability Price point Lens technology (blue light, transitions, etc.) Other (please specify): Others Patient Information Survey We value your feedback! Please take a moment to share your experience and receive a $25 gift certificate as our thanks.Section 6: Premier Eye Associate’s Mission & Impact16. Were you aware of our “One Vision” Initiative, where we partner with philanthropic eyewear vendors and donate a portion of optical sales to a different community charity each quarter?* Yes No Not sure 17. How important is it to you that our practice is involved in giving back to the community through charitable initiatives?* 1 – Not at all important 2 – Slightly important 3 – Moderately important 4 – Very important 5 – Extremely important Step 1 of 7 14%
