Patient Survey

1: Location

Please select the imaging center location where you received service:

2: Service

Which service did you receive? (Check all that apply.)

MRI

CT

X-Ray/Interventional

Mammography

Ultrasound

Nuclear/PET/PETCT

DEXA

3: Appointment Scheduling

Please rank in terms of convenience, professionalism, and expectations met.

4 - EXCELLENT

3 - GOOD

2 - AVERAGE

1 - POOR

4: Front Desk

Please rank in terms of promptness, friendliness, professionalism, and knowledge.

4 - EXCELLENT

3 - GOOD

2 - AVERAGE

1 - POOR

Employee Name (optional):

5: Technologist

Please rank in terms of promptness, friendliness, professionalism, and knowledge.

4 - EXCELLENT

3 - GOOD

2 - AVERAGE

1 - POOR

Employee Name (optional):

6: Facility

Please rank in terms of cleanliness, comfort, and location/access.

4 - EXCELLENT

3 - GOOD

2 - AVERAGE

1 - POOR

7: Imaging Center

Why did you choose our imaging center? (Check all that apply.)

Convenient Location

Previous Visit

Advertising

Insurance Referral

Physician Referral

Reputation

Other

Additional Comments? (Optional)

Please include any additional comments below.

Please contact me to discuss my experience. (optional)

I would like to be contacted to discuss my experience at the center.

Your Name:

Your Phone Number:

How did we do today?

1: Location

2: Service

3: Appointment Scheduling

4: Front Desk

5: Technologist

6: Facility

7: Imaging Center

Additional Comments? (Optional)

Please contact me to discuss my experience. (optional)