ATTACHMENT C - PATIENT SATISFACTION QUESTIONNAIRE - SAMPLE.docx

Patient Satisfaction Questionnaire – VISN 8 Eyeglasses

· Date seen by VA Optometry Clinic: ________________

· Location: ________________________

· Method of choosing your new eyeglasses: (please circle one response below)

· In person at the VA Optical Shop

· Internet/Web App

· If internet/web app was used, on a scale from 1 to 5 (with 1 being the lowest & 5 being the highest), how would you rate your experience with the following:

· Clear instructions on navigating the site

· Ease of use

· Did you need additional assistance from their online customer support in order to complete your selection? (please circle one response below)

· Yes

· No

· Additional comments related to ordering your new eyeglasses (optional): _________________________________________________________________________________

· Was the wait time to receive your new eyeglasses within the timeframe you expected/were told? (please circle one response below):

· Yes

· No

· From the date you completed your frame selection & measurements, how many days did it take to receive your new eyeglasses? _________________________

· Method of receiving your new eyeglasses (please circle one response below):

· Received/Fitted at the VA Optical Shop

· Mailed to your home

· On a scale from 1 to 5 (with 1 being the lowest & 5 being the highest), please rate your satisfaction with the following as it pertains to your new eyeglasses:

· Packaging was appropriate

· Instructions on fitting/cleaning/care were given

· Quality of workmanship

· Correct prescription

· Additional comments pertaining to your new eyeglasses (optional): _________________________________________________________________________________