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* 3. Date of Visit:

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* 4. How would you rate the following?
First Impressions...

  Excellent Very Good Meets Expectations Fair Poor N/A
Convenience of appointment time
Scheduling of appointment
Location and directions
Greeting on arrival
Cleanliness
Wait time before you were seen
Reception Facilities
Waiting Room Facilities
Changing Facilities
Scan Room
Toilet Facilities

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* 5. While you were here...

  Excellent Very Good Meets Expectations Fair Poor N/A
Explanation about the exam/test/procedure
Privacy / confidentiality
Helpfulness / professionalism of staff
If you have a disability, did we meet your needs?
Were you made as comfortable as possible for your exam?
Were you treated with dignity and respect?
Quality of care received

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* 6. On a scale of 0-10, how likely are you to recommend us to a friend or relative, if they require the service?

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* 7. Would you return to us in future if you needed to?

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* 8. Overall, were you satisfied with your experience at our facility?

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* 9. Do you have any further comments or recommendations?

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* 10. Optional

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