Eye Surgery Feedback Survey Form
We value your feedback about your recent eye surgery experience. Please take a few moments to complete this survey.
How would you rate your overall experience with your eye surgery?
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1
2
3
4
5
How satisfied are you with the results of your eye surgery?
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Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
How would you rate the professionalism of the staff?
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1
2
3
4
5
How clear and helpful was the information provided before your surgery?
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Extremely clear
Very clear
Somewhat clear
Not so clear
Not at all clear
Please rate your level of pain or discomfort during and after the surgery.
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No pain
1
2
3
4
Severe pain
5
1 is No pain, 5 is Severe pain
How likely are you to recommend our eye surgery services to others?
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Not likely
1
2
3
4
5
6
7
8
9
Extremely likely
10
1 is Not likely, 10 is Extremely likely
How would you rate the cleanliness and comfort of our facility?
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1
2
3
4
5
How would you describe the communication with your surgeon and staff?
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Excellent
Good
Average
Poor
Very poor
Please indicate your level of agreement with the following statements:
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Rows
Strongly agree
Agree
Neutral
Disagree
Strongly disagree
I felt comfortable during my visit
1
2
3
4
5
My questions were answered thoroughly
6
7
8
9
10
The recovery process was explained clearly
11
12
13
14
15
Please share any additional comments or suggestions.
Submit Feedback
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