We want to know what you think!

Please take a few minutes to answer questions about your experience with Fort Madison Eye Clinic.

We use survey information internally to improve our patient care. This information is never shared with parties outside of Fort Madison Eye Clinic; however, we may contact you if you have an issue you would like to be resolved. Dr. Peck and his staff are committed to patient satisfaction.

Please rate the following questions using scale of 1 to 5:

  • 5 – Excellent experience
  • 4 – Very good experience
  • 3 – Average
  • 2 – Fair
  • 1 – Poor
  • NA – Not Applicable or Don’t Know

Quality Assurance Survey




  1. Was our staff courteous and professional on the phone?
    5 4 3 2 1 N/A
  2. How courteous and professional was our staff during every aspect of your visit?
    5 4 3 2 1 N/A
  3. Were all your questions answered? Were we attentive to your needs?
    5 4 3 2 1 N/A
  4. How would you rate your overall experience in our facility?
    5 4 3 2 1 N/A
  5. Rate your satisfaction with Fort Madison Eye Clinic in regards to the value of our services and products
    5 4 3 2 1 N/A
  6. How well did we follow up with you if you ordered contacts or glasses?
    5 4 3 2 1 N/A
  7. Would you like to be contacted in regards to a specific issue?
    Yes No
  8. Would you recommend Fort Madison Eye Clinic to your family and friends?
    Yes No
  9. What did you like best about your experience with Fort Madison Eye Clinic?
  10. Do you have any recommendations that could improve the performance of our office?
  11. Overall, do you believe the time you spent in our office was (Check one):
    Comprehensive, just what I thought.
    Too long, could have taken less time.
    Too short, not enough time taken with my specific needs.
  12. How have you heard about Fort Madison Eye Clinic? (Check all that apply)
    Television Promotional Flyer/Mailer
    Radio Internet Search / Website
    Yellow Pages Referral from Family or Friend
    Newspaper Referral from Employer
    Insurance Plan Book / Insurance Website Location of Office
    Vision Screening
  13. Is there a staff member you would like to recognize for their service?

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