Medica Forsyth Patient Satisfaction Survey Question Title * 1. What exam did you have done today? Question Title * 2. Have you had a previous MRI, CT, or US? Yes No Question Title * 3. If you answered "yes" to an MRI, what type of MRI? Question Title * 4. Are you claustrophobic? Yes No Question Title * 5. How did you hear about us? Question Title * 6. How do you rate your overall experience? 1 2 3 4 5 6 7 8 9 10 Question Title * 7. On a scale of 1-10, how would you rate your appointment experience? Rating a) Efficiency of check in 1 2 3 4 5 6 7 8 9 10 a) Efficiency of check in Rating menu b) Waiting time in reception 1 2 3 4 5 6 7 8 9 10 b) Waiting time in reception Rating menu Comments: Question Title * 8. On a scale of 1-10 how would you rate our staff? Rating a) Friendliness & courtesy of front desk 1 2 3 4 5 6 7 8 9 10 a) Friendliness & courtesy of front desk Rating menu b) Care, concern & professionalism of tech. 1 2 3 4 5 6 7 8 9 10 b) Care, concern & professionalism of tech. Rating menu c) Explanation of your procedure 1 2 3 4 5 6 7 8 9 10 c) Explanation of your procedure Rating menu Comments: Question Title * 9. How would you compare this imaging experience with others? 1 2 3 4 5 6 7 8 9 10 Question Title * 10. If you needed another MRI, CT or Ultrasound would you consider us? Yes No Question Title * 11. If a family member needed an MRI, CT or Ultrasound would you recommend us? Yes No Question Title * 12. Please share your thoughts on how we can improve Question Title * 13. May we use you as a reference? Yes No Question Title * 14. Please share your contact information (this is not required). Thank you. Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Done