Your comments count!

Thank you in advance for providing us feedback about your experience.
 
Your comments and suggestions help us to do our best in our mission to provide excellence in care for each patient. Your information is confidential. We do not share your email or information.
 
 

* 1. Enter code indicated on your survey card

* 2. Patient Name

* 3. Name of Referring Provider or Practice

* 4. Type of Exam(s)

* 5. Date of Exam

Date
/
/

* 6. Appointment Scheduling (convenience, professionalism, met your needs)
1 = Poor   |   5 = Excellent

* 7. Location where you had your exam:

* 8. Imaging Center (comfort, location, cleanliness)
1 = Poor   |   5 = Excellent

* 9. Front Desk Personnel (professionalism, answered your questions, met your needs)
1 = Poor   |   5 = Excellent

* 10. Technologist / Exam Experience (promptness, friendliness, knowledgeable, answered your questions)
1 = Poor   |   5 = Excellent

* 11. Employee or Staff you would like to mention or recognize (and why)

* 12. Why did you choose our imaging center?
(check all that apply)

* 13. Would you recommend this facility to a friend or family member?

* 14. Would you like to be informed about health tips and community events via email?
(We do not share your email or information and you can unsubscribe at any time.)

* 15. Any other comments or concerns?

* 16. Would you like someone to contact you about any of your concerns?

* 17. Contact information:

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