| 1. Which Wisconsin Vision or Heartland Vision Location did you visit? |
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| Date of Visit: |
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| 2. Why did you choose our Company? (select all that apply) |
Referred by health professional
Referred by Friend
Saw clinic from the road
Yellow Pages
Advertising
Insurance
Website
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| 3. How easy did we make it for you to schedule a convenient appointment? |
Exceptional
Good
Average
Below Average
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| Please tell us why: (optional -- greatly appreciated) |
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| 4. How would you rate your experience with our Eye Doctor? |
Exceptional
Good
Average
Below Average
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| Please tell us why: (optional -- greatly appreciated) |
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| 5. How would you rate your experience with our optician? |
Exceptional
Good
Average
Below Average
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| Optician's Name: (optional) |
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| Please tell us why: (optional -- greatly appreciated) |
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| 6. If you were trying to access insurance benefits, were we helpful? |
Exceptional
Good
Average
Below Average
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| Please tell us why: (optional -- greatly appreciated) |
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| 7. How would you rate your overall experience with our company? |
Exceptional
Good
Average
Below Average
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| 8. Would you recommend our company to your family & friends? |
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| Why or Why Not? |
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| 9. Would you like to be contacted? |
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| Name: |
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| Email: |
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| Daytime Phone: |
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