* 1. What is the name of the diagnostic test you received?

* 2. What location did you visit?

* 3. Choose the level of satisfaction that best reflects your experience with the listed aspects of our office.

  Very Satisfied Satisfied Neutral Dissatisfied Very Dissatisfied
Calling our office to make an appointment
Time between making appointment and being seen
Receptionist was friendly and courteous
Length of total visit time
Length of time spent in reception area
Length of time waiting in dressing room
Length of time waiting in examination room
Procedure performed was explained by the technologist
Sensitivity of technologist to your illness
Questions were answered adequately by staff
How satisfied are you with the overall care you received when you visited our office?

* 4. Would you recommend this practice to a friend or relative?

* 5. If you had an encounter with a member of our billing team, was the individual professional/courteous/friendly?

* 6. Did they listen to your situation, answer your questions and provide solutions?

* 7. Have you seen any of our ads/communications recently? (check all that apply)

* 8. Comments/Suggestions

* 9. Patient Name (Optional)

* 10. Email Address (Optional)