1. Which of our locations did you visit? Choose One 7930 'O' Street2943 Pine Lake25th & SuperiorBeatriceVision Therapy
   Required field
2. What date were you in the office?
   Time?
3. How did you make your appointment? Choose One I called in to schedule.I requested an appointment online and someone contacted me.I received a postcard with my appointment date and time.
4. How quickly were you able to find an appointment that fit your schedule? Choose One Within 1-2 daysSame week
Two weeks
5. Website URL?
6. Additional Comments:
7. Please select the department(s) that cared for you during your visit.
    Eye Doctors  Clinic Tech.  Contact Lens  Eyewear  Check In/Out

Optional Patient Information

1. First Name
   Last Name
   Middle
2. Address
3. City
   State
   Zip Code
4. Home Phone
   Mobile Phone
5. Work Phone
   E-mail Address

   Invalid email address
6. Would you refer our services to others?
   Yes No
7. Whom may we thank for referring you to our office?
   First Name
   Last Name
8. Have you seen our name or heard about our services through any of the following?
    Website  Facebook  Radio  Television

    Neighborhood Magazine  Newspaper  Billboard
9. Other? (please specify)

To provide the best communication possible please answer the following

1. Do you listen to local radio stations?
   Yes No
2. If so, which ones? KFGE 98.1 FMKZKX 96.9 FMKLMY 106.3 FMKBBK 107.3 FMKUTT 99.5 FMKTFL 92.9 FMKLIN 1400 AMWOW 105.3 FMMy Bridge Radio 95.1 FMKFOR 1240 AMOther
3. Do you read any local newspapers?
   Yes No
4. If so, which ones? Seward IndependentVoice NewsBeatrice Daily SunLincoln Journal StarOmaha World HeraldOther
5. Do you read newspapers online?
   Yes No
6. If so, which ones? Seward IndependentVoice NewsBeatrice Daily SunLincoln Journal StarOmaha World HeraldOther
7. Do you use Facebook?
   Yes No
8. Do you learn more about a company through their website?
   Yes No
9. Do you read email updates from businesses?
   Yes No
10. Any additional comments about your latest experience?