Patient Satisfaction Survey

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Patient Satisfaction Survey

Please let us know about your recent experience at our office. Your survey response is anonymous and will be kept confidential. Any feedback you give will be used to improve our patient experience. Thank you for your time!

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GENERAL INFORMATION

Please answer the following questions.

Your age:

Your gender:

Female

Male

Clear selection

Office location:

Procedure(s); please select all that apply:

MRI

CT

Mammography

Ultrasound

Bone Density

X-Ray/Flouroscopy

Spinal/Joint Injection

Vascular/Interventional

How did you hear about us?

If you selected "Other" above, please let us know how you heard about us.

If you were referred to us by a doctor, what is his/her name?

EASE OF GETTING CARE

Please indicate how well we are doing in this area by answering the following questions.

Hours center is open:

Convenience of center's location:

Prompt return on phone calls:

WAITING

Please indicate how well we are doing in this area by answering the following questions.

Time in waiting room:

Time in exam room:

Waiting for tests to be performed:

STAFF

Please indicate how well we are doing in this area by answering the following questions.

Explanation of procedure and answering questions:

Respectful and courteous:

Friendly and helpful:

PAYMENT

Please indicate how well we are doing in this area by answering the following questions.

What you pay:

Explanation of charges:

Collection of payment:

FACILITY

Please indicate how well we are doing in this area by answering the following questions.

Neat and clean building:

Ease of finding where to go:

Comfort and safety while waiting:

Privacy:

CONFIDENTIALITY

Please indicate how well we are doing in this area by answering the following questions.

Keeping my personal information private:

Likelihood of referring your friends and relatives to us:

What do you like best about our center?

What do you like least about our center?

Suggestions for improvement:

If you’d like us to speak with us as a follow up to your survey, please leave a phone number or an email address where we can reach you directly. Thank you!

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