Optometric Care
 

 

Patient Forms
Optometric Care understands that our patients want to have their office visit be as smooth as possible. To help facilitate this process, we have provided our patient forms online for you to download and complete before your next visit.

Patient History Questionnaire

Patient Lifestyle Questionnaire

Privacy

NOTE: You will need Adobe Acrobat Reader to view these forms. Click here to download a free version.




The professional quality of your eye care is our concern. Our goal is to provide you with personal attention and excellence in the delivery of our services to you. Thank you for taking a few minutes to share your thoughts with us about your recent visit to Optometric Care. For completing this survey, we would like to offer you a 90-day voucher that is good for 25% off a second pair of prescription glasses or sunglasses. While you have the option of submitting this survey anonymously, please include your name in the space provided below if you wish to receive a discount voucher.

*** Voucher can not be used in conjunction with any insurance plan or other discount program. Only one survey can be completed per patient per year. Discount voucher must be used within 90 days.

Please answer the following questions on a scale of 1 to 5, with 1 being poor service/non-satisfactory and 5 being excellent service/complete satisfaction.

1. When you called the office, were you satisfied with the response from the person who answered the phone?
2. When you checked in at the front desk, was the receptionist friendly and courteous?
3. Was your time spent in the reception area and the examining room before seeing the doctor reasonable?
4. How would you rate the care and friendliness of the staff member who performed the testing before you saw the doctor?
5. How would you rate the quality of care you received from the doctor?
6. If you needed surgery and you were seen by one of our surgeons, how would rate the care he or she provided you?
7. How would you rate the service you received from the optical staff?
8. If the doctor prescribed a prescription for glasses, did you purchase your eyewear from our optical department?
9. How would you rate the quality of the eyewear that is available in our optical?
10. How would rate your overall experience in our office?
Name:
Please include your name if you wish to recieve a 25% off voucher.

You can either complete this survey online or you can choose to print it out and mail it our office at the following address:

Optometric Care, Inc.
2576 Brodhead Road
Aliquippa, Pa 15001
Attn: Chris Madron, Office Manager
 
       
© 2011 Optometric Care, Inc. Aliquippa and Monaca Pennsylvania