Referrer Survey

Question Title

* 1. How likely are you to refer your patients/clients to Horizon Radiology?

Very likely

Likely

Neutral

Not Likely

Not at all.

Other (please specify)

Question Title

* 2. How would you rate Horizon Radiology's Service?

Excellent

Good

Average

Fair

Poor

Other (please specify)

Question Title

* 3. Did you find the staff helpful and professional?

	Extremely	Very	Moderately	Slightly	Not at all
Helpful	Helpful Extremely	Helpful Very	Helpful Moderately	Helpful Slightly	Helpful Not at all
Professional	Professional Extremely	Professional Very	Professional Moderately	Professional Slightly	Professional Not at all

Question Title

* 4. Are you happy with the accuracy and turnaround time of your patients/clients reports?

Yes

No

Other (please specify)

Question Title

* 5. Was your call answered in a prompt manner?

Yes

No

Other (please specify)

Question Title

* 6. Do your patients/clients find it easy to make an appointment?

Yes

No

Other (please specify)

Question Title

* 7. Is there anything we could do to improve our service?

Question Title

* 8. Please enter your contact details for our reference only.

Name: *

Company: *

Address 1:

Address 2:

City/Town:

Email Address:

Phone Number: