This questionnaire is designed to assess the quality of our diagnostic imaging services 
provided to you. We appreciate your comments, both positive and negative.
 
Thanks in advance for taking the time to complete this questionnaire!
 
 
Contact Information:
 
Name:                                 
 

Phone Number:                
 

Best time to contact you: 


Please rate our overall service: 

    

  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion


Comment on our company:



 

CLERICAL SERVICES 

Phones answered promptly and hold time is minimal: 


  • Excellent 

  • Very Good 

  • Good 

  • Fail 

  • Poor

  • No Opinion
 Availability of appointments:


  • Excellent 

  • Very Good 

  • Good 

  • Fail 

  • Poor

  • No Opinion

Level of knowledge/courtesy of scheduling staff:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Receptionist interaction with patients:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Availability of reports:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Comment on our Clerical Services:



    
TECHNICAL SERVICES 
    
Level of professionalism/knowledge of technical staff: 
  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Technologist interaction with patients:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Policy on film copies:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion


Comment on our Technical Services:



RADIOLOGISTS 

Interaction with patients: 


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion 
Availability for consultation: 
 
  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Comments on our Radiologists:


     
    OVERALL SERVICES 
     
    Days/hours of service: 
     
  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Delivery/availability of films:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

On Line reports/images:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Patient wait time:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Overall rating of facility:


  •  Excellent 

  •  Very Good 

  •  Good 

  •  Fail 

  •  Poor

  •  No Opinion

Comments on our overall services: 


    
If you were not aware we provide a following service, please check: 
      

    •  I'm aware of your services

    •  Online Reports/Films

    •  MRI

    •  CT

    •  Fluoroscopy 

    •  X-Ray

    
Are there any other procedures that you would like us to perform?


    •  
    What changes would you like to see us make to better serve you and your patients?