Patient Satisfaction Survey Question Title * 1. Select Location SJMH - Ann Arbor SJMH - Livingston SJMH - Brighton SJMH - Oakland SJMH - Canton SJMH - Chelsea SMMH - Livonia ProMedica Hickman Hospital Other (please specify) Question Title * 2. What type of exam did you have? MRI Ultrasound X-ray CT Mammogram Biopsy Nuclear Medcine Bone Scan Other (please specify) Question Title * 3. Please rate the ease in scheduling your appointment. Very difficult Somewhat difficult Average Somewhat easy Very easy N/A or I don't know Other (please specify) Question Title * 4. How long did it take from your appointment time until you were taken in for your exam? 0-5 minutes 5-10 minutes 10-15 minutes 15-20 minutes more that 20 minutes Question Title * 5. Did you or your family speak directly to a Radiologist, Physician Assistant or Nurse Practitioner? Yes No I don't know Question Title * 6. Please rate the quality of service you received from the Technologist performing your exam Very poor Somewhat poor Average Good Excellent N/A Other (please specify) Question Title * 7. Please rate the quality of service you received from the Radiologist, Physician Assistant of Nurse Practitioner: Very poor Somewhat poor Average Good Excellent N/A Other (please specify) Question Title * 8. How would you rate your overall experience with Huron Valley Radiology? Very poor Somewhat poor Average Good Excellent Other (please specify) Question Title * 9. Would you recommend Huron Valley Radiology to friends or family? Yes No I don't know If no, why not? Question Title * 10. Please share your comments with us. Question Title * 11. Would you like someone to contact you regarding your experience? Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Done
