Patient Survey

Thank you for choosing Los Gatos Eyecare (A Professional Optometric Corporation) for your recent office visit. As part of our continuous effort to improve the quality of our services, we survey our patients to learn about their experiences with us. Please take a few moments to complete our survey.

Your comments and suggestions will be confidentially reviewed and shared with our staff to help us improve upon our services. We strive to provide you with the highest quality of care.


Dr. Polhemus, Dr. Bell and Staff

Patient Satisfaction Survey

Date of Visit:

First Visit?



Scheduling your appointment...
    Yes No
... if no, why?

1. Was the person who scheduled your appointment friendly and courteous?  
2. Were you able to get a convenient appointment?  

    Yes No
1. Were all the staff members who helped you in office friendly and courteous?  
2. Would you like to recognize any specific staff member?  

Your examination...
    Yes No
... if no, why?
1. Was your doctor courteous and professional to you?  
2. Did the doctor answer your questions and explained your conditions to your satisfaction?  

Overall Satisfaction...
    Yes No
... if no, why?
1. Did you find our eye wear selection satisfactory? If not, how can we improve our eye wear selection?  
2. Would you return to our office for your future eye care needs?  
3. Would you refer your friends and family members to our office?  
4. Below, please supply us with any additional comments that can help us make your next experience at Los Gatos Eye Care even better.