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Date and time of your visit: (Required.)

Date
Time

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Which of our clinics did you visit? (Required.)

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What was the purpose of your visit? (Select all that apply) (Required.)

Appointment booking / registration:

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1. Ease of making appointments by phone (Required.)

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2. Appointment available within a reasonable amount of time (Required.)

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3. I received clear instructions to prepare for my appointment (Required.)

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4. The administrative staff welcomed me upon arrival and assisted me in a timely manner (Required.)

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5. Considering the number of patients in the waiting room, I waited an acceptable amount of time (Required.)

Our Staff:

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6. The kindness and professionalism of the person who took your call (Required.)

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7. The friendliness and professionalism of the receptionist (Required.)

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8. The caring and concern of our technologists (Required.)

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9. The medical staff answered my questions (Required.)

Your Exam:

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10. I felt my privacy was being respected throughout my visit (Required.)

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11. The technologist introduced themselves, and explained the test I was going to have in a manner I could easily understand (Required.)

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12. I felt confident in the service I received (Required.)

Our Facility:

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13. The clinic was easy to find (Required.)

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14. Overall comfort (Required.)

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15. Cleanliness (Required.)

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16. Adequate parking (Required.)

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17. Signage and direction easy to follow (Required.)

Your Experience:

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18. The overall experience met or exceeded my expectations (Required.)

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19. I would recommend Clear Medical Imaging to my friends and family (Required.)

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20.  If you would like to provide any additional comments or information regarding how we could improve our service or if you would like to acknowledge the exceptional service provided by one of our staff members, please use the space provided below.

** Your comments will remain anonymous, however should you wish to share your experience with one of our team members and be entered into our monthly draw, please provide your name and phone number.

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Contact Information:

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