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* 1. Facility Name and Staff Member Name:

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* 2. Date of exam/service:

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* 3. UMI Technologist:

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* 4. Courtesy towards facility staff:

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* 5. Friendliness with patient:

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* 6. Overall professionalism (appearance of tech and equipment):

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* 7. Promptness:

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* 8. Overall Satisfaction:

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* 9. Is there anything we could have done better?

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