Satisfaction Survey | Acton Eyecare

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Customer Satisfaction Survey

Please let us know how your last visit went.

"*" indicates required fields

Doctor*

Service Ratings

Communication prior to appointment

Great

Good

Fair

Poor

N/A

Appointment availability

Great

Good

Fair

Poor

N/A

Waiting room time

Great

Good

Fair

Poor

N/A

Fees

Great

Good

Fair

Poor

N/A

Quality of care from staff

Great

Good

Fair

Poor

N/A

Quality of care from doctor

Great

Good

Fair

Poor

N/A

Concerns or questions answered

Great

Good

Fair

Poor

N/A

Overall quality of care

Great

Good

Fair

Poor

N/A

Scheduling

Preferred day for appointments

Preferred time for appointments

Do you plan on returning for your next comprehensive examination?

Yes

No

Please tell us why not

Would you schedule appointments online?

Yes

No

Please tell us why not

Products

Satisfaction with eyeglasses

Great

Good

Fair

Poor

N/A

Satisfaction with contact lenses

Great

Good

Fair

Poor

N/A

Range of eyeglasses selection

Identification - This section is optional.

Why did you choose us for your eye health care?

Your Name (Optional)

First Last

Additional comments

Email

This field is for validation purposes and should be left unchanged.

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Contact

Acton Eyecare
A5 - 372 Queen Street East
Acton, ON L7J 2Y5

(519) 853-4300

Hours
Monday - Friday: 9:30am - 5pm

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Eye Care Services
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