Patient Survey

We want to know what you think and we want to reward you for telling us!

Please take a few minutes to answer questions about your experience with IEC. You will receive a $20 credit on your account for any future purchase at IEC. (One time credit of $20 per patient account; must be 18 years or older.)

We use survey information internally to improve our patient care. This information is never shared with parties outside of IEC; however, we may contact you if you have an issue you would like to be resolved. IEC doctors and staff are committed to patient satisfaction.

Please rate the following questions using scale of 1 to 5:

  • 5 - Excellent experience
  • 4 - Very good experience
  • 3 - Average
  • 2 - Fair
  • 1 - Poor
  • NA - Not Applicable or Don't Know

Quality Assurance Survey

1) Was our staff courteous and professional on the phone?
5     4     3     2     1     N/A

2) How courteous and professional was our staff during every aspect of your visit?
5     4     3     2     1     N/A

3) Were all your questions answered? Were we attentive to your needs?
5     4     3     2     1     N/A

4) How would you rate your overall experience in our facility?
5     4     3     2     1     N/A

5) Rate your satisfaction with IEC in regards the value of our services and products 
5     4     3     2     1     N/A

6) How well did we follow up with you if you ordered contacts or glasses?  
5     4     3     2     1     N/A

7) Would you like to be contacted in regards to a specific issue?
Yes     No

8) Would you recommend IEC to your family and friends?
Yes     No

9) What did you like best about your experience with IEC?

10) Do you have any recommendations that could improve the performance of our office?

11) Overall, do you believe the time you spent in our office was (check one):
Comprehensive, just what I thought.
Too long, could have taken less time.
Too short, not enough time taken with my specific needs.

12) How have your heard about IEC? (Check all that apply)
Promotional Flyer/Mailer
Internet Search / Website
Yellow Pages
Referral from Friend/Family
Referral from Employer
Insurance Plan Book / Insurance Website
Location of Office
Vision Screening

13) Is there a staff member you would like to recognize for their service?

Date of Your Office Visit


Office Location

Purpose of Visit

Enter Comments Below:*

Patient Name:

Your Relationship to Patient:

Your First Name:

Your Last Name:

Are you 18 or older?





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