At Coastal Eye Associates, we strive to provide the highest quality medical care in an atmosphere that is courteous and convenient. Please help us by answering a few question about your experience at our office. The following survey is designed to give us some information and insight on your view of the services we provided to you, so we can pinpoint possible areas for improvement. All of your responses will be held confidential unless you request otherwise.   (* are required fields)

Office where I was seen *
Select One Webster - 555 E Medical Center Blvd #101, Webster, TX 77598 Fuqua - 11550 Fuqua #250, Houston, TX 77034 Pasadena - 3333 Bayshore Blvd , Pasadena, TX 77504 Alvin - 400 Medic Lane - D, Alvin, TX 77511 Texas City - 6807 Emmett F. Lowry Expressway-#102, Texas City, TX 77591

1) How professional and courteous was our staff on the phone? *
(5) Far exceeded my expectations
(4) Exceeded my expectations
(3) Met my expectations
(2) Did not meet my expectations
(1) Fell far below my expectations
(N/A) Not Applicable

2) How easy was it when you called to get the proper person or department? *
(5) Far exceeded my expectations
(4) Exceeded my expectations
(3) Met my expectations
(2) Did not meet my expectations
(1) Fell far below my expectations
(N/A) Not Applicable

3) During your office visit, how well did we LISTEN to your specific needs? *
(5) Far exceeded my expectations
(4) Exceeded my expectations
(3) Met my expectations
(2) Did not meet my expectations
(1) Fell far below my expectations
(N/A) Not Applicable

4) How well were you informed on the vision tests and exams you received? *
(5) Far exceeded my expectations
(4) Exceeded my expectations
(3) Met my expectations
(2) Did not meet my expectations
(1) Fell far below my expectations
(N/A) Not Applicable

5) How would you rate the VALUE of the service and products you received? *
(5) Far exceeded my expectations
(4) Exceeded my expectations
(3) Met my expectations
(2) Did not meet my expectations
(1) Fell far below my expectations
(N/A) Not Applicable

6) How courteous and professional was our staff during EVERY aspect of your visit? *
(5) Far exceeded my expectations
(4) Exceeded my expectations
(3) Met my expectations
(2) Did not meet my expectations
(1) Fell far below my expectations
(N/A) Not Applicable

7) How well did we follow up with you if your ordered contacts or glasses? *
(5) Far exceeded my expectations
(4) Exceeded my expectations
(3) Met my expectations
(2) Did not meet my expectations
(1) Fell far below my expectations
(N/A) Not Applicable

8) Would you recommend our practice to your family and friends? *
Yes
No

9) Overall, do you believe the time you spent in our office was (check one): *
Comprehensive, just what I expected
Too long, could have taken less time.
Too short, not enough time was taken with my specific needs.

10) If you purchased glasses or contacts somewhere other than Coastal Eye Associates, which of the following best describes the reason why you chose not to purchase from us (check all that apply):
Service
Price
Selection
Didn’t want new contacts this year
Other (Please explain below)
             

11) How did you first hear about Coastal Eye Associates? *
Television
Radio
Yellow Pages
Newspaper
Insurance Plan Book
Vision Screening
Location of Office
Promotional Flyer/Mailer
Internet Search/Website
Referral from Friend/Family
Referral from Employer
Referral from your doctor
Window Sign
Other

12) Do you have any recommendations that could improve the performance of our office?

13) I would like you to contact me in regards to a specific issue? *
Yes
No

Only if you answered YES, please let us know the best way to contact you:

Name:

Phone number

E-mail address