Feedback form

 
First Name Last Name
       
Age    
   
Email   
   
What were you treated for?
 
When was the procedure done?
Day: Month: Year:
           
At which Center was the procedure done? Who was the doctor who treated you?
 
 
Please rate us on a scale of 1 -5 for the following parameters, where 1 is extremely satisfied and 5 is extremely dissatisfied.
Pre-operative consultation
Thoroughness of Examination
Behavior of staff
Punctuality (of?)
Explanation of procedure
Queries explained satisfactorily
 
Procedure-day Experience
Behavior of staff
Behavior of Doctors
Punctuality
Fees taken as explained before
 
Post-operative Experience
Behavior of staff
Ease of getting appointments
Punctuality
Thoroughness of Examination
Explanation of Queries
 
 
Do you experience any vision problems
NO Yes (please describe your problems)
 
 
Overall, how satisfied are you with the treatment? Please rate us on a scale of 1-5 where 1 is extremely satisfied and 5 is extremely dissatisfied.
 
Would you recommend us to a friend? Why?
Yes    No
 
How did you come to know about LaseRx / HiTech Eye Surgery Clinic?
Newspaper    Magazine    Radio   Television   Friends
Google Ads     Search In (Google / Yahoo / MSN / Other)    
 
    
 
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