EyeWest Vision Clinic   
Rogers 763.428.3757  
|  
St. Michael
763.497.3754
Survey

FORM-1182
We appreciate any feedback you have on the services our clinic provides. Please fill out the survey below.

Name

Email Address

Was our staff courteous and helpful?YesNo
Were you seen in a timely manner?YesNo
Was your examination thorough?YesNo
Were you able to understand your eye condition and treatment options?YesNo
Will you refer other patients to our office?YesNo
How would you rate your overall satisfaction with our office?12345
(1=very dissatisfied, 5=exceeding expectations)

Please let us know how we may improve your experience in our office:



If you have suggestions on how we can make your future experience better, please contact our Office Manager, Wendy. Email or call 763-428-3757.
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