Patient Feedback Did you recently visit one of our clinics and have a good experience? We’d greatly appreciate it if you filled out our feedback survey. Your Name (Optional) Examination completed on the visit? X-RayBone MineralDensityUltrasoundMammogram __________________________________________________________________________________ Was the clinic easy to locate? ExcellentGoodFairNot Applicable Were you attended to promptly and courteously upon arrival? ExcellentGoodFairNot Applicable Was the examination room clean and tidy? ExcellentGoodFairNot Applicable Was the atmosphere pleasant? ExcellentGoodFairNot Applicable Do you feel that your privacy was respected throughout your visit? ExcellentGoodFairNot Applicable Do you feel you the clinic staff treated you with respect? (Doctors, Receptionists, Technologists) ExcellentGoodFairNot Applicable __________________________________________________________________________________ Were you scheduled for your appointment within 3-5 business days? YesNoNot Applicable Were you taken to the examination room in a reasonable amount of time? ExcellentGoodFairNot Applicable Would you return for another examination? YesNoNot Applicable __________________________________________________________________________________ Is there a staff member you wish to recognize as giving you a positive experience? Comments __________________________________________________________________________________ Daytime Contact TEL (format: 9051234567) __________________________________________________________________________________ Δ
