Confidential Satisfaction Survey

Date

Referring Physician:

Practice:

Our timeliness in setting up your appointment:

Cleanliness & professional appearance of our facility:

Time you were examined vs. your appointment time:

Overall courtesy and attention of our staff:

Front Desk

Comments about the Front Desk:

Mammographers

Mammography Rating

Comments on Mammographers:

Patient Coordinator

Patient Coordinator Rating

Comments on Patient Coordinator:

Ultra Sound Techs

Ultra Sound Rating

Comments on Ultra Sound Technicians:

Bone Density Techs

Bone Density Rating

Comments on Bone Density Technicians:

Plain Film Techs

Film Tech Rating

Comments onf Plain Film Technicians:

Person giving your results

Results Rating

Comments on results giver:

My understanding and promptness of test results:

My Paperwork & Insurance was handled quickly &
professionally

My overall experience at Imaging 4 Women:

May we share this information with your physician?

Did our hours meet your needs?

If not, what hours do you prefer?

Physician

Physician Rating

Comments for your physician:

How can we improve your next visit?

Additional Comments:

Please rate the Individual Courtesy and Attention given by our staff.

Front Desk Rating