Eye Designs Planning Survey
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Client Name:
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Administrator Name
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Firm 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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Phone Office
Fax
Phone Cell
Phone Home
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Best Time to Be Reached
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Email Address
Website
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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?
Yes
No
General Information
The Practice Consists of :
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#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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What type of building will the project be located in?
Professional Building
Office Building
Hospital
Home
Shopping Center/Mall
Other
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What floor is the project on?
Do you need access to a
Basement
Attic
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Is this your first time dispensing/selling eyewear?
Yes
No
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Is your project
1st-time Office
Renovation
Relocation
Satellite/Secondary Location
Expansion
Other
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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:
$1-$15,000
$15,000-$25,000
$25,000-$40,000
Over $40,000
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Style Preference:
Traditional
Contemporary
Transitional
List Preferred Eye Designs' Furniture Collection(s):
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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?
Yes
No
# of months
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Are you a member of a buying group?
Yes
No
If yes, Please specify
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Are you working with a Practice Management firm?
Yes
No
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If yes, please list
Waiting Area
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How many people do you wish to accommodate in the Waiting Area?
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Are you purchasing new waiting room chairs?
Yes
No
Do you require the following :
Children's Play Area
Patient Lav
Coat Closet
Refreshment Area
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If you require Patient Lav(s), How many?
Reception/Business Area
Number of Work Stations Required :
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Front Desk : #
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Check In #
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Check Out Business Office #
What is the number and size of file cabinets required?
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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?
Accounting
Insurance
Administrator/Manager
Surgical Scheduling
Patient Histories
Other
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Do you require an Archive/Storage Room?
Yes
No
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# of Files
Optical Dispensary
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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:
Professional
Family
Children
Upper
Middle
Budget
Please list your top three frame vendors :
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1
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2
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3
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Do you prefer
Open Browsing
Controlled Environment
Mixed
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Is Security an Issue
Yes
No
Certain Areas
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Do you require a seperate entrance to this space?
Yes
No
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How many dispensing stations do you require?
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Do you need a computer at the dispensing tables?
Yes
No
If yes, How many?
Additional Places
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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?
Yes
No
If yes, # of Frames
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Do you require an Optical Laboratory?
Yes
No
If yes
Adjustment
Tinting/Edging
Surfacing
If surfacing Lab, #sq. ft. required
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Do you require a separate Delivery/Adjustment Area in the dispensary?
Yes
No
If yes
Sit down
Stand Up
# of stations
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Do you require a separate Business Office for this area?
Yes
No
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Do you require additional waiting for this area?
Yes
No
# of Chairs
Contact Lens
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How many training stations do you require? #
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Do you prefer to train
Side by Side
Across
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Do you want the Contact Lens Area :
Semi enclosed
Enclosed
Located Near Optical
Located Near Exam Rooms
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Do you require a sink in the Contact Lens Room?
Yes
No
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Will acuities be performed in the Contact Lens Area?
Yes
No
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Do you require a separate Contact Lens Storage Area?
Yes
No
If yes, # of sq. ft.
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Do you wish to display Sunwear in the Contact Lens Room?
Yes
No
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Can the CL area also serve as the Delivery Area?
Yes
No
Data Collection & Visual Fields
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How many Pre-Test Rooms will you require? #
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Do you want the Pre-Test Area
Visible
Private
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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?
Yes
No
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Photography Room
Yes
No
Combined with V.Fields
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Special Testing Room
Yes
No
Size
Examination Rooms
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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
Right
Left
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Do you require a sink in the Exam Room?
Yes
No
Additional Equipment and/or procedure requirements in Exam Room
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Will you be purchasing new Exam/Refracting Desk(s)?
Yes
No
If yes, how many
Surgical Areas
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Do you require a Minor Surgery Suite?
Yes
No
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If yes, what size
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Will the suite serve as an additional Exam Room?
Yes
No
Ancillary Areas
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Nurse/Tech Station
Yes
No
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Dilation/Holding Area?
Yes
No
If yes, how many seats?
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Patient Education/Consultation Center?
Yes
No
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If yes, will this be in the
Drop Hold
Private Room
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Laser Room?
Yes
No
If yes, please list the type of lasers
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Visual Training Room
Yes
No
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If yes, required size
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Storage/Utility Room
Yes
No
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Computer Server Room
Yes
No
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Mechanical Room
Yes
No
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Do you require a light-signaling system?
Yes
No
Computer Requirements
Number of Computer Work Stations in Each Area
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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?
Yes
No
If yes, Please specify
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Do you have interest in a wireless network for your computer system?
Yes
No
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Have you implemented electronic medical records in your practice?
Yes
No
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If no, do you plan to implement electronic medical records in the future?
Yes
No
Doctor and Staff Requirements
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Private Doctor's Office :
Yes
No
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How Many
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If more then one doctor, can their offices be combined into one shared office?
Yes
No
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Do you require a private Doctor's Lavatory?
Yes
No
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Do you require a shower?
Yes
No
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Do you require a private entrance into the building?
Yes
No
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Is a Staff Lavatory required?
Yes
No
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Do you require a Conference Room?
Yes
No
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Do you require a Staff Lounge?
Yes
No
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Will the lounge also function as a Conference Room?
Yes
No
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Please Include Any Additional Notes/Information For Our Design Team:
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Indicates Response Required