Patient Feedback Survey

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* 2. How did you book your appointment?

Called MIC’s Central Booking phone line to book an appointment.

Used the Online Appointment Request feature on the website.

Your physician booked the examination for you.

It was a walk in x-ray examination, with no appointment required.

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* 3. What type of examination did you have?

Bone Densitometry

Breast Imaging - Automated Breast Ultrasound (ABUS)

Breast Imaging - Mammogram

Cardiac Studies

CT Scan

Gastrointestinal Imaging

MRI

Nuclear Medicine

Pain Management

Sphenopalatine Ganglion Block

Ultrasound/MSK Ultrasound

Varicose Vein Assessment and Treatment

Whole Body Composition (DXA)

X-ray

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* 4. Please rate your interaction with the following members of the MIC team:

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	N/A
Central Booking Staff	Central Booking Staff Very Satisfied	Central Booking Staff Satisfied	Central Booking Staff Dissatisfied	Central Booking Staff Very Dissatisfied	Central Booking Staff N/A
Clinic Reception Staff	Clinic Reception Staff Very Satisfied	Clinic Reception Staff Satisfied	Clinic Reception Staff Dissatisfied	Clinic Reception Staff Very Dissatisfied	Clinic Reception Staff N/A
Technologist	Technologist Very Satisfied	Technologist Satisfied	Technologist Dissatisfied	Technologist Very Dissatisfied	Technologist N/A
Nurse	Nurse Very Satisfied	Nurse Satisfied	Nurse Dissatisfied	Nurse Very Dissatisfied	Nurse N/A

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* 5. If you spent time with one of our radiologists, please rate your interaction

Very Satisfied

Satisfied

Dissatisfied

Very Dissatisfied

N/A

Very Satisfied

Satisfied

Dissatisfied

Very Dissatisfied

N/A

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* 6. Please indicate your level of satisfaction with our clinic:

	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied
Convenience of hours	Convenience of hours Very Satisfied	Convenience of hours Satisfied	Convenience of hours Dissatisfied	Convenience of hours Very Dissatisfied
Appointment availability	Appointment availability Very Satisfied	Appointment availability Satisfied	Appointment availability Dissatisfied	Appointment availability Very Dissatisfied
Amount of time spent in waiting room	Amount of time spent in waiting room Very Satisfied	Amount of time spent in waiting room Satisfied	Amount of time spent in waiting room Dissatisfied	Amount of time spent in waiting room Very Dissatisfied
Cleanliness and comfort of waiting room	Cleanliness and comfort of waiting room Very Satisfied	Cleanliness and comfort of waiting room Satisfied	Cleanliness and comfort of waiting room Dissatisfied	Cleanliness and comfort of waiting room Very Dissatisfied
Cleanliness and comfort of exam room	Cleanliness and comfort of exam room Very Satisfied	Cleanliness and comfort of exam room Satisfied	Cleanliness and comfort of exam room Dissatisfied	Cleanliness and comfort of exam room Very Dissatisfied
Location	Location Very Satisfied	Location Satisfied	Location Dissatisfied	Location Very Dissatisfied

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* 7. What was your overall impression of the services provided by MIC Medical Imaging?

Excellent

Good

Neutral

Poor

Excellent

Good

Neutral

Poor

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* 8. Any additional comments about experience - care, quality of service etc.

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* 9. Would you like to discuss your responses to this questionnaire?

Yes

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* 10. If you answered ‘yes’ to question #9, please provide the following information and we will contact you:

Name:

Email Address:

Daytime Phone Number:

Patient Feedback Survey

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* 1. Which clinic did you visit?

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* 2. How did you book your appointment?

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* 3. What type of examination did you have?

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* 4. Please rate your interaction with the following members of the MIC team:

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* 5. If you spent time with one of our radiologists, please rate your interaction

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* 6. Please indicate your level of satisfaction with our clinic:

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* 7. What was your overall impression of the services provided by MIC Medical Imaging?

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* 8. Any additional comments about experience - care, quality of service etc.

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* 9. Would you like to discuss your responses to this questionnaire?

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* 10. If you answered ‘yes’ to question #9, please provide the following information and we will contact you: