Optometrist Office Feedback Form

Optometrist Office Feedback Form — Form Fields

This feedback template includes 8 fields. Gather patient feedback on eye exam quality, optometrist communication, eyewear selection, and overall optical clinic experience. Free to customize and use on ZenBuild.

• Reason for Visit (dropdown selection, required) — options: Routine Eye Exam, New Glasses / Contact Fitting, Follow-up Appointment, Eye Concern or Symptoms
• Wait Time (rating, required) — How satisfied were you with the wait time before being seen?
• Optometrist's Thoroughness (rating, required) — Did the doctor explain your eye health clearly?
• Staff Friendliness & Professionalism (rating, required)
• Eyewear Selection (rating, optional) — If applicable, how would you rate the variety of frames and lenses available?
• Overall Satisfaction (rating, required)
• Would you return for future visits? (multiple choice, required) — options: Yes, Probably yes, Undecided, No
• Additional Comments (long text, optional)