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Elite Vision Form 4 - Survey
HIPAA
Compliance
1
How satisfied are you with our Elite Vision's
doctor
?
N/A
Not Satisfied
Satisfied
Very Satisfied
Please pick one
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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N/A
Row 0, Column 0
Not Satisfied
Row 0, Column 1
Satisfied
Row 0, Column 2
Very Satisfied
Row 0, Column 3
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2
How satisfied are you with our Elite Vision's
optician/receptionist
?
N/A
Not Satisfied
Satisfied
Very Satisfied
Please pick one
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Please pick one
N/A
Row 0, Column 0
Not Satisfied
Row 0, Column 1
Satisfied
Row 0, Column 2
Very Satisfied
Row 0, Column 3
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3
How satisfied are you with our Elite Vision's
office cleanliness
?
Not clean
Somewhat clean
Clean
Very Clean
Please pick one
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Please pick one
Not clean
Row 0, Column 0
Somewhat clean
Row 0, Column 1
Clean
Row 0, Column 2
Very Clean
Row 0, Column 3
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4
How satisfied are you with our Elite Vision's
wait time
?
Not Satisfied
Satisfied
Very Satisfied
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Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
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Not Satisfied
Row 0, Column 0
Satisfied
Row 0, Column 1
Very Satisfied
Row 0, Column 2
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5
How satisfied are you with our Elite Vision's
product selections
?
Not enough frames
Enough frames
More than enough frames
Please pick one
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Please pick one
Not enough frames
Row 0, Column 0
Enough frames
Row 0, Column 1
More than enough frames
Row 0, Column 2
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6
How can we improve our service?
Please include your name & number if you want us to reach out to you. Thank you!
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