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Complete Practice Design Questionnaire
General Information
Client Name:* Project Location:
(if different from above)*
Practice Name:* Office Phone #:*
Office Manager Name:* Cell Phone #:*
Street Address:* Email:*
Address 2: Website:*
City:* Should this project be handled confidentially?
Yes No
Zip Code:*
Practice Attributes
Number of Opthalmologists (MDs):*
Number of Optometrists (ODs):*
Number of Opticians:*
Number of Office Staff:*
Total Square Footage:*
Ceiling Height:*
Building Type:*
Medical Building Office Building Hospital
Mall Shopping Center Other
Optical Dispensary Space?*
Yes No
Your Project is a:*
New Office Remodeling Relocation
Add'l Location Expansion Other
Number of current locations?*
How many more planned for the future?*
What is the target date of completion?*
Proposed budget for your optical dispensary:*
$1-$9,999 $10,000-$24,999
$25,000-$40,000 Over $40,000
Preferred Look:*
Traditional Modern/Contemp.
Would you be interested in our 3-year free financing?*
Yes No
Are you a Vision Source member?*
Yes No
Are you working with any other Practice
Management groups?*
Yes No
If yes, please name:*
Waiting Room/Section
How many patients typically sit in the waiting area?*
Are you planning to purchase new waiting room furniture?*
Yes No
Do you require a children's play area?*
Yes No
Reception/Business Area
How many private offices are required, i.e. business offices, accounting, etc.?*
Dispensing Information
Number of Frames:
High-end Mid-end Low-end Yes No Not Sure
Men's: Lockable Displays:
Women's: Children's Area:
Children's: Reception/Waiting Area:
Sunglasses: Total Number of Frames:
Client Type: Professionals Upper Middle Low Income
Number of Dispensing Tables:
Additional Notes:
Additional Spaces
Number of in-house labs:*
Where would you like the contact lens area located?*
Enclosed Within Optical Near Exam Rooms
How many contact lens stations do you require?*
Do you wish to merchandise sunglasses in the contact lens area?*
Yes No
Pre-Test & Visual Fields
Will there be a pre-test room? If so, How many?*
Yes No How Many?
Notes for instrument and equipment exceptions:
Whate type of instruments will you have in the pre-test area?
Please list:*
Examination Rooms
How many total exam rooms are required?:*
Do you require a light-signaling system?:*
Yes No
What size?:*
Architect Information If you're currently working with an architect, please provide their contact information here.
Name: Phone:
Firm Name: Email:
Floor Plan Upload If you have a digital floorplan and/or images of your store in JPEG, PNG or PDF formats, please upload them here to help us better serve your design needs.
Image Upload:
Image Upload:
Image Upload:
*denotes required field