Patient Satisfaction Survey

Our goal is to provide you with quality radiology services in a comfortable and convenient setting. We are striving to improve the service we offer and welcome your feedback and suggestions. Please take a few minutes to complete this survey about your visit. If you prefer, you may download a paper copy of the form to complete and drop in the mail. The postage has been prepaid.

Thank you for your time and input. All comments will remain confidential.

[Adobe Acrobat PDF]Patient Satisfaction Survey - Download a copy of the survey or complete the form below:



Please rate your level of satisfaction by selecting your answers below:


5=Very Satisfied 4=Satisfied 3=Unsatisfied 2=Extremely Unsatisfied 1=No Opinion
Scheduling
1.Did you schedule your appointment?
If "No" or "Don't Know" skip to the registration section		 Yes No Don't Know
2.Your ability to schedule an appointment that was convenient 5 4 3 2 1
3.The adequacy of the instructions about how to prepare for your exam 5 4 3 2 1
4.The courtesy and efficiency of the scheduling staff 5 4 3 2 1
5.Your overall level of satisfaction with the scheduling process 5 4 3 2 1

Registration
1.The courtesy and efficiency of the receptionist 5 4 3 2 1
2.The comfort and appearance of the waiting room 5 4 3 2 1
3.Your overall level of satisfaction with the registration process 5 4 3 2 1

Your Procedure
1.Did you have an appointment?
If "No" or "Don't know" skip to question 4.		 Yes No Don't Know
2.Did you have to wait past your scheduled appointment time? No Yes Don't Know
3.Approximately how long was your wait?
Taken Early No Wait 1-15 mins 16-30 mins 31+ mins
4.Your overall Satisfaction with the waiting time 5 4 3 2 1
5.The technologist's sensitivity and ability to communicate 5 4 3 2 1
6.Thoroughness in explaining the procedure 5 4 3 2 1
7.Respect for your privacy 5 4 3 2 1
8.The comfort and appearance of the exam room 5 4 3 2 1
9.Your overall level of satisfaction with your procedure 5 4 3 2 1
10.Would you recommend Fairfax Radiological Consultants to a friend of relative? Yes No Don't Know

We would appreciate additional comments:

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