Laser Eye Surgery Lasik Eye Surgery Center
     
  How To Reach Us »
 
 

Patient Feedback Form


 
You can schedule your consultation using our online appointment system. All you have to do is fill in the form below and hit the submit button. You will then receive an email in 2-3 working days confirming the date and time of your consultation. No urgent/emergency appointments will be scheduled through our online appointment system. We recommend scheduling your preferred appointment date at least a week from the date of submitting the form. Having a consultation does not obligate you to have the procedure. All information given by you is strictly confidential and will merely assist us in preparing for your visit.
 
 
  1.
First Name:   Last Name:
 
       
       
  2.
What were you treated for?
 
       
       
  3.
When was the procedure done?
Day:
Month:
Year:
 
       
       
  4.
At which Center was the procedure done? Who was the doctor who treated you?
 
       
       
  5.
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    
         
       
  6
Do you still need to wear glasses?
Yes No
 
       
       
  7
Do you experience any vision problems?
No Yes (please describe your problems)
 
       
       
  8
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.
 
       
       
  9
Would you recommend LASIK to a friend? Why?
Yes No
 
 
 
       
   
       
 
 
       
 
   
Copyright © 1994-2009
New Vision Laser Centers
 
Lasik Home      |      Sitemap      |      Resources