Your responses will help us improve the tools, services and care we provide. Thank you in advance for your feedback!Please enable JavaScript in your browser to complete this form.Are you completing this survey for yourself or for another person?I am completing this survey for myselfI am completing this survey for another personYour name *First nameLast namePatient's name *First nameLast nameEmail *PhoneAbout your Assessment Specialist (select all that apply)? *They treated you with dignity and respectThey were sensitive to your needs and preferencesThey reviewed your medical historyThey listened to your concernsThey spoke using a language you could understandThey provided good explanationsThey gave you clear instructions about next stepsHow would you rate your Assessment Specialist? *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5How would you rate our office (reception, cleanliness, your physical comfort)? *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Did you use the Visual Stress and Colorimetry Assessment Tool (VSCAT)?YesNoDon’t knowHow would you rate the VSCAT system? *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Comments or recommendations about the VSCAT:How would you rate your overall experience? *Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5Are you willing to provide a testimonial? *YesYes – AnonymouslyNoTestimonialAdditional comments or recommendations?Submit
