Take the Victoria Eye Center Patient Survey
    


Please take a moment to complete the following patient survey to rate your visit at Victoria Eye Center.

 

Name:
Email:
Daytime Phone Number:
Date of your visit: //           mm/dd/yyyy
Location of your exam:
Which doctor did you visit with:
Please rate your wait time:
1 2 3 4     5
Please rate your experience with the staff:
1 2 3 4     5
Please rate your overall experience at Victoria Eye Center:
1 2 3 4     5
Please rate how well we answered all of your questions?
1 2 3 4     5
Did any member of our staff go above and beyond to make you feel welcome and to meet all of your needs?
Yes No
If so, please tell us who:
Will you continue to visit us for your eyecare and recommend us to family and friends?
Yes No
Would you like to be contacted so we can further discuss your recent visit?
Yes No
Question/Comment:
 

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