Quality Care Survey

Complete survey to be registered for monthly drawing to win a $25 gift card.

Thank you for choosing Dayton Eye Associates. Our goal is to provide outstanding quality patient service. Your feedback is very important to us, as we will use your opinion to improve the quality of our care and services.

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Patient Name

E-Mail Address

Date of Birth

Date of Service

Location Main Office North Office South Office Troy Office Centerville Office

Doctor Choose Your Doctor Adam R. Cloud, M.D. Leah K. Cloud, M.D. David E. Denlinger, M.D. Walter C. Hartel, M.D., F.A.C.S. S. Fareed Hasan, M.S., M.D. Amy M. Kopp. M.D. Richard Liston, M.D. Paul Moyer, M.D. Jonathan Pargament, M.D. Jennifer M. Shade, MD Mary Runkle, M.D. Andriena F. Erickson, O.D. Karen McPherson, O.D. C. Patrick Carroll, M.D. A. Marie Martinek, M.D. Bruce Buerck, M.D. Scott Schoenberger, M.D. Martin F. Wilkes, M.D.

Survey

1) The ease of making an appointment by phone:

Poor

Fair

Good

Very Good

Excellent

2) The professionalism and courtesy of our staff:

Poor

Fair

Good

Very Good

Excellent

3) The quality of medical care provided:

Poor

Fair

Good

Very Good

Excellent

4) Medical concerns were explained in a way you could understand:

Poor

Fair

Good

Very Good

Excellent

5) The amount of time you spent waiting was reasonable given your ophthalmic condition:

Poor

Fair

Good

Very Good

Excellent

6) Your overall satisfaction with our practice:

Poor

Fair

Good

Very Good

Excellent

Additional Comments:

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Call (937) 320-2020 or contact us to learn more.