Feedback Questionnaire

We would be grateful for a few minutes of your time with this brief questionnaire in relation to your recent visit to our practice. At Elcott Opticians we take customer care seriously and thank you for your custom and participation.

Was this your first visit, or are you an existing patient?
First visitExisting patient

How easy was it to make an appointment?
Very easySomewhat easyDifficultVery Difficult

How courteous were the staff at the reception desk?
Very courteousCourteousNot so courteousRude

How competent was the Optometrist who examined your eyes?
OutstandingGoodAdequateNeeds improvement

Did you feel that the Optometrist spent adequate time with you?
YesNo

Did you feel that your eye examination was thorough?
YesNo

How satisfied do you feel about any products purchased?
Not applicableExtremely satisfiedVery satisfiedSatisfiedNot satisfied

If you didn’t purchase any products at your last visit, how likely are you to purchase a product in the next 12 months?
LikelyNot likely

Would you recommend Elcott Opticians to your family and friends?
YesNo

Any other comments?

Please let us know if any comments above can be shared with existing or potential new patients?
YesNoNot applicable

Personal Information - this section is optional

Your Name (optional)

Your Email (optional)