Medica Forsyth Patient Satisfaction Survey

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* 1. What exam did you have done today?

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* 2. Have you had a previous MRI, CT, or US?

Yes

No

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* 3. If you answered "yes" to an MRI, what type of MRI?

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* 4. Are you claustrophobic?

Yes

No

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* 5. How did you hear about us?

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* 6. How do you rate your overall experience?

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* 7. On a scale of 1-10, how would you rate your appointment experience?

	Rating
a) Efficiency of check in	a) Efficiency of check in Rating menu
b) Waiting time in reception	b) Waiting time in reception Rating menu

Comments:

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* 8. On a scale of 1-10 how would you rate our staff?

	Rating
a) Friendliness & courtesy of front desk	a) Friendliness & courtesy of front desk Rating menu
b) Care, concern & professionalism of tech.	b) Care, concern & professionalism of tech. Rating menu
c) Explanation of your procedure	c) Explanation of your procedure Rating menu

Comments:

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* 9. How would you compare this imaging experience with others?

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* 10. If you needed another MRI, CT or Ultrasound would you consider us?

Yes

No

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* 11. If a family member needed an MRI, CT or Ultrasound would you recommend us?

Yes

No

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* 12. Please share your thoughts on how we can improve

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* 13. May we use you as a reference?

Yes

No

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* 14. Please share your contact information (this is not required). Thank you.

Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number: