Patient Survey


	Excellent	Good	Fair	Poor	n/a
1. Overall experience
2. Courtesy of staff
3. Ease of registration
4. Comfort of waiting area
5. Comfort of changing area
6. Explanation of exam procedures by our staff
7. Accessibility of location and office
8. Promptness of service
9. Friendliness and courteousness of receptionist
10. Caring attitude of technologist performing exam
11. Time between making appointment and being seen
12. Type of exam you had
13. How did you choose Mountain Medical Imaging Center?
14. Suggestions/Comments on how we can improve our service:
15. Would you recommend Mountain Medical Imaging Center to a friend or relative?		Yes: No:
16. If no, please provide additional details:
17. Additional comments:
Name:
Address:
Email Address:
I would like to speak with your Patient Relations Representative. My phone number is:
Date of patient visit: