X-RAY ASSOCIATES PATIENT SURVEY

Please let us know about your patient experience at any of our X-ray Associates Clinics.

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1. Type of Service Provided (Required.)

X-Ray

Ultrasound

BMD

Nuclear Medicine

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2. Please provide the name of the staff member, so that we can follow up (Required.)

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3. Date of Service Provided

Date / Time

Date

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4. Which X-Ray Associates location did you receive the indicated services from (Required.)

679 Davis Drive., Newmarket

250 Harding Blvd., Richmond Hill

125 Pedersen Drive., Aurora

955 Major Mackenzie Dr., Vaughan

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5. Please rate each item by selecting the rating that best describes your opinion. Please complete all fields prior to submitting

	Poor	Good	Excellent	N/A
Waiting time: How long you had to wait to get an appointment at this clinic	Waiting time: How long you had to wait to get an appointment at this clinic Poor	Waiting time: How long you had to wait to get an appointment at this clinic Good	Waiting time: How long you had to wait to get an appointment at this clinic Excellent	Waiting time: How long you had to wait to get an appointment at this clinic N/A
Waiting time: How was the length of time before you were seen?	Waiting time: How was the length of time before you were seen? Poor	Waiting time: How was the length of time before you were seen? Good	Waiting time: How was the length of time before you were seen? Excellent	Waiting time: How was the length of time before you were seen? N/A
Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff Poor	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff Good	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff Excellent	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff N/A
Ease of getting information: Willingness of the clinic staff to answer questions	Ease of getting information: Willingness of the clinic staff to answer questions Poor	Ease of getting information: Willingness of the clinic staff to answer questions Good	Ease of getting information: Willingness of the clinic staff to answer questions Excellent	Ease of getting information: Willingness of the clinic staff to answer questions N/A
Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests Poor	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests Good	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests Excellent	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests N/A
Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness)	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) Poor	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) Good	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) Excellent	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) N/A
Safety and Security: How well did the staff provide for the safety and security of your belongings	Safety and Security: How well did the staff provide for the safety and security of your belongings Poor	Safety and Security: How well did the staff provide for the safety and security of your belongings Good	Safety and Security: How well did the staff provide for the safety and security of your belongings Excellent	Safety and Security: How well did the staff provide for the safety and security of your belongings N/A
Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing)	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) Poor	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) Good	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) Excellent	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) N/A
Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic Poor	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic Good	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic Excellent	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic N/A
Overall quality of care: How would you evaluate the services and the treatment you received in this clinic	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic Poor	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic Good	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic Excellent	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic N/A
Cleanliness of the Facility: How clean was the facility	Cleanliness of the Facility: How clean was the facility Poor	Cleanliness of the Facility: How clean was the facility Good	Cleanliness of the Facility: How clean was the facility Excellent	Cleanliness of the Facility: How clean was the facility N/A

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6. Would you recommend this clinic to a friend or family member if they needed the services of this clinic

Yes

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7. What suggestions or changes would you recommend to improve our service?

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8. If you would like to be contacted about your concerns please add your name and telephone number

Full Name

Phone Number

X-RAY ASSOCIATES PATIENT SURVEY

We appreciate your Feedback!

Question Title

* 1. Type of Service Provided (Required.)

Question Title

* 2. Please provide the name of the staff member, so that we can follow up (Required.)

Question Title

* 3. Date of Service Provided

Question Title

* 4. Which X-Ray Associates location did you receive the indicated services from (Required.)

Question Title

* 5. Please rate each item by selecting the rating that best describes your opinion. Please complete all fields prior to submitting

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* 6. Would you recommend this clinic to a friend or family member if they needed the services of this clinic

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* 7. What suggestions or changes would you recommend to improve our service?

Question Title

* 8. If you would like to be contacted about your concerns please add your name and telephone number

1. Type of Service Provided (Required.)

2. Please provide the name of the staff member, so that we can follow up (Required.)

3. Date of Service Provided

4. Which X-Ray Associates location did you receive the indicated services from (Required.)

5. Please rate each item by selecting the rating that best describes your opinion. Please complete all fields prior to submitting

6. Would you recommend this clinic to a friend or family member if they needed the services of this clinic

7. What suggestions or changes would you recommend to improve our service?

8. If you would like to be contacted about your concerns please add your name and telephone number