We strive to provide the highest quality medical care in an atmosphere that is courteous and convenient. Please help us by answering a few questions about your surgery and experience at our office. The following survey is designed to give us some information and insight on your view of the services we provided to you, so we can pinpoint possible areas for improvement. All of your responses will be held confidential unless you request otherwise.  (* are required fields)

Why did you choose Dr. Lipsky and Advanced Laser Vision for your surgery?

Which surgery did you have? *
LASIK
PRK
Verisyse
ReStor
ReZoom

How would you rate your current vision? *

Distance	Near	All Quality
(5) Excellent	(5) Excellent	(5) Excellent
(4) Very Good	(4) Very Good	(4) Very Good
(3) Good	(3) Good	(3) Good
(2) Fair	(2) Fair	(2) Fair
(1) Poor	(1) Poor	(1) Poor

How satisfied are you with your surgery? *
(5) Extremely Satisfied
(4) Somewhat Satisfied
(3) Neutral
(2) Somewhat Dissatisfied
(1) Very Dissatisfied

What are you able to do without glasses that you couldn’t do before surgery?

Is there anything about your vision correction that is disappointing?

Do you have any recommendations that could improve the performance of our office:
      • during the consultation and examination?
     

      • on surgery day?
     

      • during your post operative care?
     

Any comments about the care provide to you by:
      • Dr. Lipsky?
     

      • Other staff members?
     

I would like you to contact me in regards to a specific issue. *
Yes
No

Only if you answered YES, please let us know the best way to contact you:

Name:

Phone number

E-mail address