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Please take our Radiology Patient Survey
Date of Visit
Time of Arrival:
Time
:
Hours
Minutes
AM
What type of appointment?
BONE DENSITY
CT
ECHO
MAMMO
MRI
NUC MED
PET
ULTRASOUND
X-RAY
Your Age:
Please Grade Your Experience for: APPOINTMENT TIME
Excellent
Good
Average
Fair
Poor
Please Grade Your Experience for: REGISTRATION PROCESS & STAFF ATTITUDE
Excellent
Good
Average
Fair
Poor
Please Grade Your Experience for: PROCEDURE WAS CONDUCTED
Excellent
Good
Average
Fair
Poor
Please Grade Your Experience for: INFORMATION AND INSTRUCTIONS PROVIDED
Excellent
Good
Average
Fair
Poor
Please Grade Your Experience for: PHYSICIAN & STAFF'S CONCERN FOR MY NEEDS
Excellent
Good
Average
Fair
Poor
Please Grade Your Experience for: MY OVERALL CARE
Excellent
Good
Average
Fair
Poor
Please Grade Your Experience for: MY OVERALL CONCERN FOR MY PRIVACY
Excellent
Good
Average
Fair
Poor
How can we better meet your needs?
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