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* 1. Location

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* 2. What is the name of the study you received today?

BIOPSY

CT

DEXA

ECHO

FLUORO

MAMMO

MRI

NUC MED

PAIN MGMT

PET

US

XRAY

OTHER/UNKNOWN

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* 3. Scheduling: Did you schedule your appointment?

Yes

No (If "No", please skip to Registration Section)

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* 4. Please indicate your level of satisfaction:

	Very Satisfied (5)	Satisfied (4)	Unsatisfied (3)	Extremely Unsatisfied (2)	No Opinion (1)
SCHEDULING	SCHEDULING Very Satisfied (5)	SCHEDULING Satisfied (4)	SCHEDULING Unsatisfied (3)	SCHEDULING Extremely Unsatisfied (2)	SCHEDULING No Opinion (1)
1. Your ability to schedule an appointment that was convenient	1. Your ability to schedule an appointment that was convenient Very Satisfied (5)	1. Your ability to schedule an appointment that was convenient Satisfied (4)	1. Your ability to schedule an appointment that was convenient Unsatisfied (3)	1. Your ability to schedule an appointment that was convenient Extremely Unsatisfied (2)	1. Your ability to schedule an appointment that was convenient No Opinion (1)
2. The adequacy of the instructions about how to prepare for your exam	2. The adequacy of the instructions about how to prepare for your exam Very Satisfied (5)	2. The adequacy of the instructions about how to prepare for your exam Satisfied (4)	2. The adequacy of the instructions about how to prepare for your exam Unsatisfied (3)	2. The adequacy of the instructions about how to prepare for your exam Extremely Unsatisfied (2)	2. The adequacy of the instructions about how to prepare for your exam No Opinion (1)
3. The courtesy and efficiency of the scheduling staff	3. The courtesy and efficiency of the scheduling staff Very Satisfied (5)	3. The courtesy and efficiency of the scheduling staff Satisfied (4)	3. The courtesy and efficiency of the scheduling staff Unsatisfied (3)	3. The courtesy and efficiency of the scheduling staff Extremely Unsatisfied (2)	3. The courtesy and efficiency of the scheduling staff No Opinion (1)
4. Your overall level of satisfaction with the scheduling process	4. Your overall level of satisfaction with the scheduling process Very Satisfied (5)	4. Your overall level of satisfaction with the scheduling process Satisfied (4)	4. Your overall level of satisfaction with the scheduling process Unsatisfied (3)	4. Your overall level of satisfaction with the scheduling process Extremely Unsatisfied (2)	4. Your overall level of satisfaction with the scheduling process No Opinion (1)
REGISTRATION	REGISTRATION Very Satisfied (5)	REGISTRATION Satisfied (4)	REGISTRATION Unsatisfied (3)	REGISTRATION Extremely Unsatisfied (2)	REGISTRATION No Opinion (1)
1. The courtesy and efficiency of the receptionist	1. The courtesy and efficiency of the receptionist Very Satisfied (5)	1. The courtesy and efficiency of the receptionist Satisfied (4)	1. The courtesy and efficiency of the receptionist Unsatisfied (3)	1. The courtesy and efficiency of the receptionist Extremely Unsatisfied (2)	1. The courtesy and efficiency of the receptionist No Opinion (1)
2. The comfort and appearance of the waiting room	2. The comfort and appearance of the waiting room Very Satisfied (5)	2. The comfort and appearance of the waiting room Satisfied (4)	2. The comfort and appearance of the waiting room Unsatisfied (3)	2. The comfort and appearance of the waiting room Extremely Unsatisfied (2)	2. The comfort and appearance of the waiting room No Opinion (1)
3. Your overall level of satisfaction with the registation process	3. Your overall level of satisfaction with the registation process Very Satisfied (5)	3. Your overall level of satisfaction with the registation process Satisfied (4)	3. Your overall level of satisfaction with the registation process Unsatisfied (3)	3. Your overall level of satisfaction with the registation process Extremely Unsatisfied (2)	3. Your overall level of satisfaction with the registation process No Opinion (1)
YOUR PROCEDURE	YOUR PROCEDURE Very Satisfied (5)	YOUR PROCEDURE Satisfied (4)	YOUR PROCEDURE Unsatisfied (3)	YOUR PROCEDURE Extremely Unsatisfied (2)	YOUR PROCEDURE No Opinion (1)
5. The technologist's sensitivity and ability to communicate	5. The technologist's sensitivity and ability to communicate Very Satisfied (5)	5. The technologist's sensitivity and ability to communicate Satisfied (4)	5. The technologist's sensitivity and ability to communicate Unsatisfied (3)	5. The technologist's sensitivity and ability to communicate Extremely Unsatisfied (2)	5. The technologist's sensitivity and ability to communicate No Opinion (1)
6. Thoroughness in explaining the procedure	6. Thoroughness in explaining the procedure Very Satisfied (5)	6. Thoroughness in explaining the procedure Satisfied (4)	6. Thoroughness in explaining the procedure Unsatisfied (3)	6. Thoroughness in explaining the procedure Extremely Unsatisfied (2)	6. Thoroughness in explaining the procedure No Opinion (1)
7. Respect for your privacy	7. Respect for your privacy Very Satisfied (5)	7. Respect for your privacy Satisfied (4)	7. Respect for your privacy Unsatisfied (3)	7. Respect for your privacy Extremely Unsatisfied (2)	7. Respect for your privacy No Opinion (1)
8. The comfort and appearance of the exam room	8. The comfort and appearance of the exam room Very Satisfied (5)	8. The comfort and appearance of the exam room Satisfied (4)	8. The comfort and appearance of the exam room Unsatisfied (3)	8. The comfort and appearance of the exam room Extremely Unsatisfied (2)	8. The comfort and appearance of the exam room No Opinion (1)
9. Your overall level of satisfaction with your procedure	9. Your overall level of satisfaction with your procedure Very Satisfied (5)	9. Your overall level of satisfaction with your procedure Satisfied (4)	9. Your overall level of satisfaction with your procedure Unsatisfied (3)	9. Your overall level of satisfaction with your procedure Extremely Unsatisfied (2)	9. Your overall level of satisfaction with your procedure No Opinion (1)

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* 5. Your Procedure: Did you have an appointment?

Yes

No

Don't Know

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* 6. Your Procedure: Did you have to wait past your scheduled appointment time?

No

Yes

Don't Know

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* 7. Your Procedure: Approximately How Long Was Your Wait?

Taken Early

No Wait

1-15 Minutes

16-30 Minutes

30+ Minutes

No Opinion

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* 8. Your Procedure: Would you recommend Fairfax Radiological Consultants to a friend or relative?

Yes

No

Don't Know

No Opinion

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* 9. We would appreciate additional comments:

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* 10. Date of Contact (if received by telephone, or social media)

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* 11. Patient Name (optional)

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* 12. Internal Action Taken

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* 13. At what email address would you like to be contacted?