Did you receive the appointment time that you wanted?
Yes
No

Wait time prior to scan:
About what was expected
Longer than expected
Shorter than expected

Was the receptionist friendly and helpful to you?
1. Poor
2. Below Average
3. Average
4. Good
5. Great

Was the technologist friendly and helpful to you?
1. Poor
2. Below Average
3. Average
4. Good
5. Great

Did the technologist adequately explain the procedure of the scan to
your satisfaction?
1. Poor
2. Below Average
3. Average
4. Good
5. Great

Rank the staffs' concern for your comfort.
1. Poor
2. Below Average
3. Average
4. Good
5. Great

Rank the staffs' concern for your privacy.
1. Poor
2. Below Average
3. Average
4. Good
5. Great

Comfort of waiting room?
1. Poor
2. Below Average
3. Average
4. Good
5. Great

Cleanliness of waiting center?
1. Poor
2. Below Average
3. Average
4. Good
5. Great

Is there anything we could change to better serve you?

Would your recommend our facility to your friends of family? (if no, why?)
Yes
No

If you selected (No) please indicate why in the field below

Did you ask your doctor to send you to our facility or did the doctor suggest you come
to our facility?
I requested your facility
Dr. requested your facility

Name

*** You may remain anonymous by leaving this question blank

May we contact you to discuss your feedback?
Yes
No

Additional Notes/Comments

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