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Date of Service*
MM slash DD slash YYYY
Who did you interact with during your visit? (Check all that apply)*
- Reception Staff
- Doctor
- Optical Staff
How was your experience with our Reception staff?*
- Very Good
- Satisfactory
- Needs Improvement
How would you describe the Reception staff?*
- Confident
- Knowledgeable
- Courteous
- Professional
- Helpful
- Responsive
- Other (please specify)
Other*
How was your experience with your Doctor?*
- Very Good
- Satisfactory
- Needs Improvement
How would you describe your Doctor?*
- Confident
- Knowledgeable
- Courteous
- Professional
- Helpful
- Responsive
- Other (please specify)
Other*
How was your experience with our Optical staff?*
- Very Good
- Satisfactory
- Needs Improvement
How would you describe the Optical staff?*
- Confident
- Knowledgeable
- Courteous
- Professional
- Helpful
- Responsive
- Other (please specify)
Other*
How was your overall experience?*
- Very Good
- Satisfactory
- Needs Improvement
Comments
Would you like to recognize an employee for outstanding service?
- Yes
Employee/Staff Person*
Reason
Your Name*
Your Email*
May we use your comments for our website, staff training, etc.?*
- Yes
- Yes, but I would like to remain anonymous
- Training only
- No
Phone
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Vibrant Vision + Optical · 4285 Commercial Street SE, Suite 140 · Salem, Oregon 97302
OPEN: 8:30am until 5:30pm MON/TUE/THU, 6:30pm WED, and 4:30pm FRI · CLOSED: SAT/SUN

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