For Patients

X-Ray Patient Survey

Thanks for helping us focus specifically on your needs. We'd like to know more about the people who visit our offices for x-ray services, and we need your help. This survey takes less than two minutes and leaving your name and contact information is entirely up to you. When you click the final "submit" button at the end, you will be returned to the page you just left. Thanks again for your help.

Full Name: Phone #: (optional)

1. Which office did you visit?

2. Were you treated courteously by the receptionist? Yes No

Were you treated courteously by the technologist? Yes No

3. Did you have to wait for your examination?

4. Was an alternative clinic suggested to you? Yes No

5. Were you given clear instructions by the receptionist? Yes No

Were you given clear instructions by the technologist? Yes No

6. Were the signs posted throughout the department helpful? Yes No

7. Were you offered a gown when the use of one was necessary? Yes No

8. Did you feel that your privacy was respected? Yes No

9. Was it made clear what to expect following the exam? Yes No

10. When did you expect your doctor to have a written report by?

1-2 days
1 week
2 weeks

11. Overall, on a scale of 1-5, how satisfied were you with the services you received?

12. Do you have any suggestions that would improve our service?

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