Patient Survey

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Laser Vision Center Cataract Center Dry Eye Center Optical Boutique

Jackson Eye Associates

Customer Satisfaction Survey

About You

1. What is your gender?

Male	Female

2. What is your ethnic origin?

	African American
	Asian
	Caucasian
	Hispanic
	Native American
	Other

3. What is your age?

Under 18	19-25	26-35	36-50	51-65	Over 65

4. What is your marital status?

Single	Married	Divorced	Widowed

5. How long have you been a patient at JEA?

Less than 1 year	1-2 years	3-4 years	More than 5 years

This section of the survey asks for your opinion about many different issues.
Please read each statement and choose the answer that best corresponds to your level of agreement or disagreement.

6. Telephone:

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
The phone was answered by the third ring:
When I spoke to a JEA employee, they were courteous:
When I spoke to a JEA employee, they were efficient:
It did not take too long to make my appointment:
I received an appointment date and time in a reasonable amount of time:
I was not put on hold for an excessive amount of time:
The JEA employee answered all of my questions:
The JEA employee mentioned JEA Optical:

7. Waiting Area:

8. Front Desk/Check-In:

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
I was greeted in a friendly manner:
The JEA staff was efficient:
The JEA staff was courteous:
The front desk staff was neat in appearance:
The front desk staff answered all of my questions:
The front desk staff satisfactorily explained all forms to me:
The front desk staff assisted me with my paperwork:
The JEA staff satisfactorily explained all my financial obilgations to the office:
The front desk staff was helpful:
The front desk staff mentioned JEA optical:

9. Clinical Staff

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
The JEA technicians were efficient:
The JEA technicians were courteous:
The JEA technicians were neat in appearance:
The JEA technician identified his or herself when I was called from the waiting room:
I did not feel rushed by the technician:
All testing that was performed was explained to me prior to the testing:
All questions I directed to the technician were answered:
The JEA technician kept all instruments and machines clean:
The technician mentioned JEA Optical:

10. Doctor

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
I had a sufficient amount of time with my doctor:
The doctor answered all of my questions:
I received a thorough examination by the doctor:
If I received any medication, its use and purpose was explained to me:
If I received treatment, the treatment and possible outcomes were explained to me:
My doctor was genuinely interested in what I said:
I did not feel rushed during my appointment:
My doctor mentioned JEA Optical:

11. Check-Out

	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
I was greeted in a friendly manner.
The check-out staff explained all my financial obligations to the office:
The check-out staff was neat in appearance:
The check-out staff made my next appointment in a timely manner:
The check-out staff was courteous:
The check-out staff mentioned JEA Optical:

12. Optical

13. General

14. What do you like best about JEA?

15. What can we do to improve JEA?

16. Please feel free to offer any additional thoughts or comments:

17.

Doctor's name:
Date of appointment:

Optional

18. If you would like to receive special JEA Optical discounts just for filling out this survey, please provide us with the following information:

Name:
Address:
Phone Number:
Email Address:

19. Would you like to receive quarterly newsletters, and special offers from JEA?

	Yes
	No

Thank you.
www.jacksoneye.com

Jackson Eye Associates of Jackson, MS is now offering free LASIK eye surgery consultations. Click here to contact us!

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Strongly Agree

Strongly Disagree

Not Applicable

The waiting room was clean:

The waiting room had current reading material:

The waiting room was well organized:

Coffee was available in the waiting area:

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