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Page One

1. Date of Visit

calendar

2. Which office did you visit?

Medical Office Building	Northern Heights	Crosskeys

3. The scheduling staff was pleasant and professional.

4. Who made your appointment?

I did	My doctor's office did	I did not have an appointment

5. The reception staff was pleasant and professional.

6. The reception process was quick and efficient.

7. Were you seen on time?

8. If not, how long did you wait to be seen?

9. How was the wait?

10. The technologist:

Space Cell	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Not Applicable
was professional
was thorough
was knowledgeable
explained my exam to my satisfaction

11. The nurse:

Space Cell	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Not Applicable
was professional
was thorough
was knowledgeable
explained my exam to my satisfaction

12. How did you hear about us?

my doctor	friend/family member	insurance plan	internet

13. Have you visited other radiology offices in the past?

14. If yes, how did today's visit compare to your visit elsewhere?

15. Why was today's visit better or worse?

16. Other Comments

If you would like us to contact you regarding your visit, please provide your name and contact information below.

17. Your Name

18. Daytime Phone

19. E-mail Address

20.

I would like to be contacted via Email / Phone

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