Laser Eye Surgery
Lasik Eye Surgery Center
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Patient Feedback Form
If you have undergone LASIK at New Vision, we would like to receive feedback on your experience. Please take some time out and fill in the form below:
 
  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
 
 
 
       
   
       
 
 
       
 

 

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