erience.
Patient Information
First name:
Last name:
Please Tell Us About Your Visit
Which of our facilities did you visit?
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Select Facility
Referring Physician Name:
Please select physician...
Other:
Search last, first name
(Other)
(max 50)
Select Head Scan
Brain
Posterior Fossa
IAC
Pituitary
Brainstem
Orbits
Select Spine Scan
Cervical
Thoracic
Lumbar
Sacrum
Select Joint Scan
Hip
Knee
Ankle
Shoulder
Elbow
Wrist
Select Vascular Scan
Interacranial MRA
Neck MRA
Thoracic Aorta
Select Miscellaneous Scan
Pelvis
Abdomen
Mediastinum
Exam Performed:
MRI
CT
Ultrasound
Nuclear Imaging
Other:
How did you hear about our facility?
Select from list
Physician's Office
Yellow Pages
Internet
Driving By
Insurance Company
Previous Visit
Other
How long did you have to wait for your exam upon arrival?
Select Wait Time
5 minutes or less
10 minutes
20 minutes
30 minutes or more
Would you use us again or recommend us to a friend?
YES
NO
Excellent
Above
Average
Satisfactory
Poor
Our location was convenient and accessible
Our reception area was clean and tidy
Our front office staff was helpful and courteous
Our technologist was helpful and courteous
Our registration process was easy and efficient
The procedure was properly explained to you
Our scheduling procedure and availability met your needs
The billing and collection process was properly explained
How would you rate our service overall?
Comments:
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