Visual Health Patient Survey

We're committed to monitoring the quality of service we provide, as part of an ongoing improvement process, please help us by filling out this survey; thank you for your participation.

Patient Survey Form

Please rate the following aspects of our office:

  • Excellent Good Poor
  • Excellent Good Poor
  • Excellent Good Poor
  • Excellent Good Poor
  • Excellent Good Poor
  • Yes No

How long did you have to wait?

  • 0 to 7 days 1 to 2 weeks 2 to 4 weeks
  • 1 to 10 mins 10 to 20 mins 0 to 30 mins.
  • 1 to 10 mins 10 to 20 mins 0 to 30 mins.
  • less than 1 hr. 1 hr more than 1 hr.

Additional Information

  • Friendly & helpful Average Varies each visit Poor service


  • Very likely Somewhat Likely Unlikely

  • Yes Sign Me Up No Thank You
Thank you for your participation!