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Feedback

We respect and value your opinion. Please tell us what you think about our Doctor, Staff, web site, clinic, products, and services. Please provide us with your contact information, so we will be able to reach you in case we have any questions.

	Excellent	Very Good	Good	Fair	Poor
1. Overall satisfaction with doctor
2. Thoroughness of the care received
3. Clarity of the doctor’s explanations
4. Doctors' listening to your concerns/questions
5. Friendliness and courtesy of the doctor
6. Friendliness and courtesy of the staff
7. Convenience of the office hours
8. Ease of making an appointment
9. Length of time you waited in the office
10. Fit and appearance of your eyewear and/or contact lenses
11. If you have eye insurance, rate the level of coverage
12. If you have medical-eye insurance, please enter your insurance company name in the "Additional Comments" section below. Please include any additional comments in this section as well.

Additional Comments/Vision Insurance:

Your Contact Information:

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Title
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Telephone
FAX
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Super Vision Center Contact Information:

If you would like to reach us by any other form of communication, see below. If you prefer the hardcopy format, kindly print this form and drop it in the office, the mail, or fax it to the number below.

Telephone: 714-979-2021

FAX: 714-549-3367

Postal address: 3301 S. Harbor Blvd. Suite 104, Santa Ana, CA 92704

General Information: DrBerke@supervisioncenter.com

Please take a few minutes to complete the following patient satisfaction survey:

Additional Comments/Vision Insurance:

Your Contact Information:

Super Vision Center Contact Information:

If you would like to reach us by any other form of communication, see below. If you prefer the hardcopy format, kindly print this form and drop it in the office, the mail, or fax it to the number below.