Vision Care Feedback Survey
This comprehensive vision care feedback form helps optometry practices and eye care centers collect meaningful patient feedback. Cover all aspects of the vision care experience from appointment scheduling to exam quality, eyewear selection, and follow-up care. The form uses a matrix question format to efficiently rate multiple service dimensions while gathering actionable insights for practice improvement.
Try the Form
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export function visionCareFeedbackSurvey(form: FormTs) {
// Vision Care Feedback - Eye doctor/optometrist patient satisfaction survey
// Demonstrates: MatrixQuestion, StarRating, RatingScale, Dropdown, Datepicker, conditional visibility
// ============================================
// HEADER
// ============================================
form.addRow(row => {
row.addTextPanel('header', {
label: 'Vision Care Feedback',
computedValue: () => 'Help us improve your eye care experience. Your feedback is confidential.',
customStyles: {
backgroundColor: '#0284c7',
color: 'white',
padding: '24px',
borderRadius: '12px',
textAlign: 'center'
}
});
});
// ============================================
// SECTION 1: Visit Details
// ============================================
const visitSection = form.addSubform('visitSection', {
title: 'Your Visit'
});
visitSection.addRow(row => {
row.addDatepicker('visitDate', {
label: 'Date of your visit',
maxDate: () => new Date().toISOString().split('T')[0]
}, '1fr');
row.addDropdown('visitType', {
label: 'Type of visit',
options: [
{ id: 'comprehensive', name: 'Comprehensive Eye Exam' },
{ id: 'contact', name: 'Contact Lens Fitting' },
{ id: 'glasses', name: 'Glasses Selection/Fitting' },
{ id: 'followup', name: 'Follow-up Appointment' },
{ id: 'emergency', name: 'Urgent/Emergency Visit' },
{ id: 'other', name: 'Other' }
]
}, '1fr');
});
visitSection.addRow(row => {
row.addCheckboxList('visitPurpose', {
label: 'Reason for visit (select all that apply)',
options: [
{ id: 'routine', name: 'Routine checkup' },
{ id: 'prescription', name: 'Update prescription' },
{ id: 'newGlasses', name: 'New glasses/frames' },
{ id: 'contacts', name: 'Contact lenses' },
{ id: 'dryEyes', name: 'Dry eyes/discomfort' },
{ id: 'vision', name: 'Vision problems' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 2: Overall Satisfaction
// ============================================
const satisfactionSection = form.addSubform('satisfactionSection', {
title: 'Overall Satisfaction',
customStyles: () => {
const rating = satisfactionSection.starRating('overall')?.value();
if (rating === null || rating === undefined) return { padding: '16px' };
if (rating >= 4) return { backgroundColor: '#dcfce7', padding: '16px', borderRadius: '8px' };
if (rating >= 3) return { backgroundColor: '#fef9c3', padding: '16px', borderRadius: '8px' };
return { backgroundColor: '#fee2e2', padding: '16px', borderRadius: '8px' };
}
});
satisfactionSection.addRow(row => {
row.addStarRating('overall', {
label: 'How would you rate your overall experience?',
maxStars: 5,
size: 'lg',
alignment: 'center',
showCounter: true,
showConfettiOnMax: true
});
});
satisfactionSection.addRow(row => {
row.addRatingScale('recommend', {
label: 'How likely are you to recommend us to friends and family?',
preset: 'nps',
showCategoryLabel: true,
showSegmentColors: true,
isVisible: () => satisfactionSection.starRating('overall')?.value() !== null
});
});
// ============================================
// SECTION 3: Service Quality Matrix
// ============================================
const qualitySection = form.addSubform('qualitySection', {
title: 'Service Quality',
isVisible: () => satisfactionSection.starRating('overall')?.value() !== null
});
qualitySection.addRow(row => {
row.addMatrixQuestion('serviceMatrix', {
label: 'Please rate each aspect of your visit',
rows: [
{ id: 'scheduling', label: 'Ease of scheduling appointment', isRequired: true },
{ id: 'waitTime', label: 'Wait time in office', isRequired: true },
{ id: 'staffFriendly', label: 'Staff friendliness', isRequired: true },
{ id: 'examThorough', label: 'Thoroughness of eye exam' },
{ id: 'doctorComm', label: 'Doctor communication & explanation' },
{ id: 'eyewearSelect', label: 'Eyewear selection & assistance' },
{ id: 'pricing', label: 'Pricing transparency' }
],
columns: [
{ id: 'poor', label: 'Poor' },
{ id: 'fair', label: 'Fair' },
{ id: 'good', label: 'Good' },
{ id: 'excellent', label: 'Excellent' },
{ id: 'na', label: 'N/A' }
],
striped: true,
fullWidth: true
});
});
// ============================================
// SECTION 4: Doctor Rating
// ============================================
const doctorSection = form.addSubform('doctorSection', {
title: 'Your Eye Care Provider',
isVisible: () => satisfactionSection.starRating('overall')?.value() !== null
});
doctorSection.addRow(row => {
row.addStarRating('doctorRating', {
label: 'Rate your eye doctor/optometrist',
maxStars: 5,
size: 'md',
alignment: 'left'
}, '1fr');
row.addStarRating('staffRating', {
label: 'Rate the office staff',
maxStars: 5,
size: 'md',
alignment: 'left'
}, '1fr');
});
doctorSection.addRow(row => {
row.addEmojiRating('careFeeling', {
label: 'How did your provider make you feel?',
preset: 'satisfaction',
size: 'md',
showLabels: true,
alignment: 'center'
});
});
// ============================================
// SECTION 5: Issues & Improvements (for lower ratings)
// ============================================
const issuesSection = form.addSubform('issuesSection', {
title: 'Help Us Improve',
isVisible: () => {
const rating = satisfactionSection.starRating('overall')?.value();
return rating !== null && rating !== undefined && rating <= 3;
},
customStyles: { backgroundColor: '#fef2f2', padding: '16px', borderRadius: '8px' }
});
issuesSection.addRow(row => {
row.addSuggestionChips('issues', {
label: 'What areas need improvement?',
suggestions: [
{ id: 'waitTime', name: 'Long wait times' },
{ id: 'scheduling', name: 'Hard to schedule' },
{ id: 'communication', name: 'Poor communication' },
{ id: 'rushed', name: 'Felt rushed' },
{ id: 'prices', name: 'High prices' },
{ id: 'selection', name: 'Limited eyewear selection' },
{ id: 'billing', name: 'Billing issues' },
{ id: 'parking', name: 'Parking/location' }
],
alignment: 'center'
});
});
issuesSection.addSpacer();
issuesSection.addRow(row => {
row.addTextarea('issueDetails', {
label: 'Please tell us more about your concerns',
placeholder: 'We take your feedback seriously and want to make things right...',
rows: 3,
autoExpand: true
});
});
// ============================================
// SECTION 6: Positive Feedback (for higher ratings)
// ============================================
const praiseSection = form.addSubform('praiseSection', {
title: 'What We Did Right',
isVisible: () => {
const rating = satisfactionSection.starRating('overall')?.value();
return rating !== null && rating !== undefined && rating >= 4;
},
customStyles: { backgroundColor: '#ecfdf5', padding: '16px', borderRadius: '8px' }
});
praiseSection.addRow(row => {
row.addSuggestionChips('highlights', {
label: 'What made your visit great?',
suggestions: [
{ id: 'professional', name: 'Professional care' },
{ id: 'friendly', name: 'Friendly staff' },
{ id: 'thorough', name: 'Thorough exam' },
{ id: 'explained', name: 'Clear explanations' },
{ id: 'quick', name: 'Quick service' },
{ id: 'selection', name: 'Great eyewear selection' },
{ id: 'value', name: 'Good value' },
{ id: 'clean', name: 'Clean facility' }
],
alignment: 'center'
});
});
// ============================================
// SECTION 7: Follow-up
// ============================================
const followupSection = form.addSubform('followupSection', {
title: 'Follow-up',
isVisible: () => satisfactionSection.starRating('overall')?.value() !== null
});
followupSection.addRow(row => {
row.addCheckbox('contactMe', {
label: 'I would like someone to contact me about my experience'
});
});
followupSection.addRow(row => {
row.addTextbox('phone', {
label: 'Phone number',
placeholder: '(555) 123-4567',
isVisible: () => followupSection.checkbox('contactMe')?.value() === true
}, '1fr');
row.addDropdown('bestTime', {
label: 'Best time to call',
options: [
{ id: 'morning', name: 'Morning (9am-12pm)' },
{ id: 'afternoon', name: 'Afternoon (12pm-5pm)' },
{ id: 'evening', name: 'Evening (5pm-8pm)' }
],
isVisible: () => followupSection.checkbox('contactMe')?.value() === true
}, '1fr');
});
// ============================================
// SECTION 8: Summary
// ============================================
const summarySection = form.addSubform('summarySection', {
title: 'Feedback Summary',
isVisible: () => satisfactionSection.starRating('overall')?.value() !== null
});
summarySection.addRow(row => {
row.addTextPanel('summary', {
computedValue: () => {
const overall = satisfactionSection.starRating('overall')?.value();
const nps = satisfactionSection.ratingScale('recommend')?.value();
const category = satisfactionSection.ratingScale('recommend')?.npsCategory();
const doctor = doctorSection.starRating('doctorRating')?.value();
const staff = doctorSection.starRating('staffRating')?.value();
const visitType = visitSection.dropdown('visitType')?.value();
const highlights = praiseSection.suggestionChips('highlights')?.value() || [];
const issues = issuesSection.suggestionChips('issues')?.value() || [];
if (overall === null || overall === undefined) return '';
let emoji = overall >= 4 ? '👁️✨' : overall >= 3 ? '👁️' : '👁️💧';
let status = overall >= 4 ? 'Satisfied' : overall >= 3 ? 'Neutral' : 'Needs Attention';
let summary = `${emoji} Vision Care Feedback\n`;
summary += `${'═'.repeat(28)}\n\n`;
summary += `⭐ Overall: ${overall}/5 stars (${status})\n`;
if (visitType) {
const visitLabels: Record<string, string> = {
'comprehensive': 'Comprehensive Eye Exam',
'contact': 'Contact Lens Fitting',
'glasses': 'Glasses Selection',
'followup': 'Follow-up',
'emergency': 'Emergency',
'other': 'Other'
};
summary += `📋 Visit: ${visitLabels[visitType] || visitType}\n`;
}
if (nps !== null && nps !== undefined) {
summary += `📊 NPS: ${nps}/10 (${category})\n`;
}
if (doctor !== null && doctor !== undefined) {
summary += `👨⚕️ Doctor: ${doctor}/5 stars\n`;
}
if (staff !== null && staff !== undefined) {
summary += `👥 Staff: ${staff}/5 stars\n`;
}
if (highlights.length > 0) {
summary += `\n✨ Highlights: ${highlights.length} selected`;
}
if (issues.length > 0) {
summary += `\n⚠️ Concerns: ${issues.length} noted`;
}
return summary;
},
customStyles: () => {
const rating = satisfactionSection.starRating('overall')?.value();
const base = {
padding: '16px',
borderRadius: '8px',
whiteSpace: 'pre-wrap',
fontFamily: 'monospace',
fontSize: '13px'
};
if (rating !== null && rating !== undefined && rating >= 4) {
return { ...base, backgroundColor: '#dcfce7', borderLeft: '4px solid #22c55e' };
} else if (rating !== null && rating !== undefined && rating <= 2) {
return { ...base, backgroundColor: '#fee2e2', borderLeft: '4px solid #ef4444' };
}
return { ...base, backgroundColor: '#fef9c3', borderLeft: '4px solid #eab308' };
}
});
});
// ============================================
// FORM CONFIGURATION
// ============================================
form.configureSubmitButton({
label: 'Submit Feedback',
isVisible: () => satisfactionSection.starRating('overall')?.value() !== null
});
form.configureCompletionScreen({
type: 'text',
title: 'Thank you for your feedback!',
message: 'Your input helps us provide better vision care for all our patients. We truly appreciate you taking the time to share your experience.'
});
}
Frequently Asked Questions
When should I send this survey to patients?
Send the survey within 24-48 hours after the patient's visit while the experience is fresh. If the patient received new glasses or contacts, consider a follow-up survey 1-2 weeks later to assess product satisfaction.
What aspects of vision care does this form cover?
The form covers the complete patient journey: appointment scheduling, wait time, eye exam quality, doctor communication, staff friendliness, eyewear selection assistance, pricing transparency, and overall satisfaction.
Can I customize the service matrix questions?
Yes, you can fully customize the matrix rows to match your specific services. Add or remove aspects like contact lens fitting, pediatric eye care, specialty testing, or optical dispensing based on your practice offerings.
How do I handle negative feedback from patients?
The form includes conditional follow-up questions for dissatisfied patients. When someone rates their experience below 3 stars, additional questions appear to understand the specific issues. Consider implementing a callback system for low scores.
Is this form HIPAA compliant?
The form template collects satisfaction feedback only, not protected health information (PHI). However, ensure your data storage and transmission methods are HIPAA compliant if you're collecting any patient identifiers alongside the feedback.