Please take a moment to let us know how we are doing and we’ll give you $10. Your opinion and feedback is very important to us. Participate in our Patient Satisfaction Survey and we'll mail you a $10 gift certificate that can be used for any future purchase with any insurance benefit or promotional discount. You can even give it to a friend or family member for them to use. Please note that $10 gift certificates may not be used for current balances or previous purchases. There is a limit of three (3) Patient Satisfaction Survey $10 gift certificates per household per year.
Doctor ---Dr. Osama SaidDr. Asma KhanDr. Sanjay PatelDr. Amjad Badwan
Date of your office visit ...
Reason for your visit: * Annual Eye Health Evaluation Eye problem requiring urgent medical attention. Follow up for diagnosed eye problem. Noticed vision change - wanted to update glasses/contact lenses.
Your Name: * First Last
Relationship to patient: * ---SelfSpouseParentGuardianOther
Are you 18 or older? * Yes No
Email *
1. When calling our office, how professional and courteous was our staff on the phone? * One of the best experiences I've had in a Doctor's office. Better than most experiences in other offices. About the same as other offices I've visited. Worse than in other offices I've visited. I wouldn't return. N/A
2. During your office visit, how well did we listen to your specific needs? * One of the best experiences I've had in a Doctor's office. Better than most experiences in other offices. About the same as other offices I've visited. Worse than in other offices I've visited. I wouldn't return. N/A
3. How well were you educated on the vision tests and exams you received? * One of the best experiences I've had in a Doctor's office. Better than most experiences in other offices. About the same as other offices I've visited. Worse than in other offices I've visited. I wouldn't return. N/A
4. How would you rate the value of the services and products you received? * One of the best experiences I've had in a Doctor's office. Better than most experiences in other offices. About the same as other offices I've visited. Worse than in other offices I've visited. I wouldn't return. N/A
5. How courteous and professional was our staff during every aspect of your visit? * One of the best experiences I've had in a Doctor's office. Better than most experiences in other offices. About the same as other offices I've visited. Worse than in other offices I've visited. I wouldn't return. N/A
6. How well did we follow up with you if you ordered contacts or glasses? * One of the best experiences I've had in a Doctor's office. Better than most experiences in other offices. About the same as other offices I've visited. Worse than in other offices I've visited. I wouldn't return. N/A
7. Would you recommend our practice to your family and friends? * Yes No
8. If you are a new patient, were you made aware that you can download patient forms at home from our website in order to reduce your time spent in the office? Yes No I'm already a Triangle Eye Institute patient
9. What did you like best about your experience in our office?
10. Do you have any recommendations that could improve the performance of our office?
11. Overall, do you believe the TIME you spent in our office was (check one): * Comprehensive, just what I thought. Too long, could have taken less time. Too short, not enough time taken with my specific needs.
12. How did you first hear about Triangle Eye Institute? * Television Radio Yellow Pages Promotional Flyer/Mailer Internet Search Referral from Friend/Family Newspaper Insurance Plan Book/Website Vision Screening Location of Office Referral from Employer Window Sign
13. If you purchased eyewear somewhere other than Triangle Eye Institute, which of the following best describes the reason why you chose not to purchase from us (check all that apply): Service Price Selection Didn't want new glasses this year. OtherAlso, please tell us where you made your purchase:
14. If you purchased contacts somewhere other than Triangle Eye Institute, which of the following best describes the reason why you chose not to purchase from us (check all that apply): Service Price Selection Didn't want new contacts this year. Other
15. Are there any staff members you would like to recognize for their service?
16. Would you like for us to contact you in regards to a specific issue? * Yes No
17. Please provide any additional comments below
Morpheus would like to know if you are human? *
