Eye Care Clinic Feedback Form

Eye Care Clinic Feedback Form — Form Fields

This feedback template includes 10 fields. Gather patient feedback on eye exam quality, eyewear selection, staff service, and overall visit. Free to customize and use on ZenBuild.

• Patient Name (text, optional)
• Email Address (email, optional)
• Visit Purpose (dropdown selection, required) — options: Routine Eye Exam, Contact Lens Fitting, Glasses Selection, Medical Concern, Other
• Doctor Expertise & Thoroughness (rating, required)
• Staff Friendliness (rating, required)
• Eyewear Selection (rating, optional)
• Wait Time (rating, required)
• Office Environment (rating, required)
• Overall Satisfaction (multiple choice, required) — options: Very Satisfied, Satisfied, Neutral, Dissatisfied
• Comments or Suggestions (long text, optional)