We appreciate your Feedback!

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

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* 2. Date of Service Provided

Date

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* 3. Which X-Ray Associates location did you receive the indicated services from

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

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

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

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

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