subject_line
Eye Designs Planning Survey
Client Name:
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Firm Name
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Administrator Name
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Street Address
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City
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State
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Zip Code
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Where Is Your Project Located (City & State)
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Phone Office
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Fax
Phone Cell
Phone Home
Best Time to Be Reached
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Email Address
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Website
Submitted By
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Title:
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Date Submitted
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How did you hear of Eye Designs?
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Is This Project Confidential?
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Yes
No
General Information
The Practice Consists of :
#MDs
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#ODs
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#Opticians
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#Other
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Total Square Footage :
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Optical Square Footage
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Ceiling Height
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Elevator Dimensions
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What type of building will the project be located in?
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Professional Building
Office Building
Hospital
Home
Shopping Center/Mall
Strip Center
Other
Other
What floor is the project on?
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Do you need access to a
Basement
Attic
Is this your first time dispensing/selling eyewear?
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Yes
No
Is your project
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1st-time Office
Renovation
Relocation
Satellite/Secondary Location
Expansion
Other
Other
If you have multiple locations, how many?
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What is the estimated date of completion for this project?
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What is the proposed budget for your displays:
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$1-$15,000
$15,000-$25,000
$25,000-$40,000
Over $40,000
Style Preference:
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Traditional
Contemporary
Transitional
List Preferred Eye Designs' Furniture Collection(s):
Name of Architect
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Phone #
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Email
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Name of Contractor
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Phone #
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Email
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Would you be interested in our financing program?
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Yes
No
# of months
Are you a member of a buying group?
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Yes
No
If yes, Please specify
Are you working with a Practice Management firm?
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Yes
No
If yes, please list
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Waiting Area
How many people do you wish to accommodate in the Waiting Area?
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Are you purchasing new waiting room chairs?
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Yes
No
Do you require the following :
Children's Play Area
Patient Lav
Coat Closet
Refreshment Area
If you require Patient Lav(s), How many?
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Reception/Business Area
Number of Work Stations Required :
Front Desk : #
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Check In #
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Check Out Business Office #
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What is the number and size of file cabinets required?
File Type
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Total Number of Files
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Patient Files #
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Width
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Depth
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General Files #
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Width
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Depth
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What staff functions require private offices?
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Accounting
Insurance
Administrator/Manager
Surgical Scheduling
Patient Histories
Other
Other
Do you require an Archive/Storage Room?
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Yes
No
# of Files
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Optical Dispensary
How many total frames do you need to display? #
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Men's #
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Women's #
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Children's #
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Sunwear #
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Boutique #
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Other #
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Describe your Target Clientele:
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Professional
Family
Children
Upper
Middle
Budget
Please list your top three frame vendors :
1
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2
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3
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Do you prefer
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Open Browsing
Controlled Environment
Mixed
Is Security an Issue
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Yes
No
Certain Areas
Do you require a seperate entrance to this space?
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Yes
No
How many dispensing stations do you require?
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Do you need a computer at the dispensing tables?
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Yes
No
If yes, How many dispensing tables require computers?
Additional Places
Lab #
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Delivery/Adjustment #
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Digital P.O.P System #
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Other #
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Do you require a dedicated Children's Display?
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Yes
No
If yes, # of Frames
Do you require an Optical Laboratory?
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Yes
No
If yes
Adjustment
Tinting/Edging
Surfacing
If surfacing Lab, #sq. ft. required
Do you require a separate Delivery/Adjustment Area in the dispensary?
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Yes
No
If yes
Sit down
Stand Up
# of stations
Do you require a separate Business Office for this area?
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Yes
No
Do you require additional waiting for this area?
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Yes
No
# of Chairs
Contact Lens
How many training stations do you require? #
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Do you prefer to train
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Side by Side
Across
Do you want the Contact Lens Area :
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Semi enclosed
Enclosed
Located Near Optical
Located Near Exam Rooms
Do you require a sink in the Contact Lens Room?
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Yes
No
Will acuities be performed in the Contact Lens Area?
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Yes
No
Do you require a separate Contact Lens Storage Area?
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Yes
No
If yes, # of sq. ft.
Do you wish to display Sunwear in the Contact Lens Room?
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Yes
No
Can the CL area also serve as the Delivery Area?
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Yes
No
Data Collection & Visual Fields
How many Pre-Test Rooms will you require? #
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Do you want the Pre-Test Area
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Visible
Private
What data instruments would you like to include in the Pre-Test Area? Please list..
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Do you require a separate Visual Fields Room?
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Yes
No
Photography Room
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Yes
No
Combined with V.Fields
Special Testing Room
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Yes
No
Size
Examination Rooms
What is the total number of rooms you require? #
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No. of Rooms
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Width
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Length
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No. of Rooms
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Width
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Length
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When facing the patient chair, do you want the stand on the
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Right
Left
Do you require a sink in the Exam Room?
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Yes
No
Additional Equipment and/or procedure requirements in Exam Room
Will you be purchasing new Exam/Refracting Desk(s)?
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Yes
No
If yes, how many
Surgical Areas
Do you require a Minor Surgery Suite?
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Yes
No
If yes, what size
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Will the suite serve as an additional Exam Room?
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Yes
No
Ancillary Areas
Nurse/Tech Station
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Yes
No
Dilation/Holding Area?
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Yes
No
If yes, how many seats?
Patient Education/Consultation Center?
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Yes
No
If yes, will this be in the
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Drop Hold
Private Room
Laser Room?
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Yes
No
If yes, please list the type of lasers
Visual Training Room
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Yes
No
If yes, required size
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Storage/Utility Room
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Yes
No
Computer Server Room
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Yes
No
Mechanical Room
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Yes
No
Do you require a light-signaling system?
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Yes
No
Computer Requirements
Number of Computer Work Stations in Each Area
Waiting Room :
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Reception/Buisness :
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Optical Sales Area :
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Delivery/Adj. :
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Lab :
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Contact Lens Area :
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Data Collection & V.F. :
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Special Testing :
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Exam Rooms :
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Minor Surgery Suite :
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Nurse's Station :
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Drop/Hold :
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Visual Training :
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Doctor's Office :
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Lounge :
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Conference :
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Do you currently have Practice Management Computer Software?
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Yes
No
If yes, Please specify
Do you have interest in a wireless network for your computer system?
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Yes
No
Have you implemented electronic medical records in your practice?
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Yes
No
If no, do you plan to implement electronic medical records in the future?
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Yes
No
Doctor and Staff Requirements
Private Doctor's Office :
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Yes
No
How Many
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If more than one doctor, can their offices be combined into one shared office?
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Yes
No
Do you require a private Doctor's Lavatory?
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Yes
No
Do you require a shower?
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Yes
No
Do you require a private entrance into the building?
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Yes
No
Is a Staff Lavatory required?
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Yes
No
Do you require a Conference Room?
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Yes
No
Do you require a Staff Lounge?
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Yes
No
Will the lounge also function as a Conference Room?
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Yes
No
Please Include Any Additional Notes/Information For Our Design Team:
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