Name *

Consultation Date ... *

1. Was your call to our facility answered promptly and efficiently?

2. During your first contact with BLC was the staff friendly and informative?

3. On consultation day what was your impression of the facility and our staff?

4. Did your consultation commence at the appointed time? If not, how long did you wait?

5. How complete did you find the consultation process in terms of patient education?

6. How could we have made the visit more beneficial to your particular needs?

8. At any time, were our educational materials provided to you? Yes No

Are there any suggestions for additions or improvements of this material (brochure and DVD)?

9. How did you hear about Burlinton Laser Eye Centre and Dr. Jeff Machat ? Please specify media: i.e., television, radio, print, billboard or other?

10. Have you or do you intend to schedule surgery? Yes No

If no, why?

11. Any additional comments to better serve our patients are welcomed.

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Thank you for your time in completing this survey. Your comments are important to our commitment to continuous improvement in serving our patients.