At Golden Vision, your satisfaction is very important to us. Please complete the survey below to help us provide the best service possible.

1. Convenience of our office hours.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

2. The treatment you received when you called to set up your appointment.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

3. The greeting you received when you arrived at the office for your appointment.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

4. Overall appearance of the office.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

5. Promptness with which you were seen by the doctor.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

6. The explanation and recommendations from your doctor concerning your eye health.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

7. Doctor's friendliness and courtesy.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

8. Staff's friendliness and courtesy.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

9. The choices available in frames and contacts.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

10. Your overall experience at Golden Vision.

Excellent Good Satisfactory Less than Satisfactory Poor N/A (Not Applicable)

11. Would you recommend Golden Vision to a family member or friend?

Yes No Maybe

12. How did you hear about Golden Vision?

Family/friend Website Newspaper/magazine ad Location Radio ad Golden Vision employee Mailing Other

13. Please provide additional comments and/or a testimonial about your experience at Golden Vision.

Store Location:	Golden San Gabriel Optometric Vision Center Golden Rowland Heights Optometry
Name:
Address:
City:
State:
Zip Code:
Phone:
E-Mail Address:

I consent to the use of my name and this text for advertising and promotional purposes in connection to my experience with Golden Vision without additional compensation.