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Patient Satisfaction Survey

Thank you for giving us the opportunity to serve you and we hope your experience was pleasant. In order to provide excellent service or make needed improvements, your feedback is very important to us. Please take a moment to answer our questions below.

Name:  (optional)

1) How did you learn about Crossroads MRI?

Physician referral - Name of Referring Dr.
Word of Mouth
Advertising - Kind:
Other

2) Was the location and accessibility of the facility convenient to you?

Very Satisfied
Satisfied
Somewhat Satisfied
Dissatisfied

Comments:

3) How would you rate the knowledge, courtesy and helpfulness of the staff?

Excellent
Good
Fair
Poor

Comments:

4) Were the billing and payment procedures clearly explained?

Yes
No

Comments:

5) Was your rate time more than 30 minutes?

Yes
No

Wait time:

6) Was the waiting area clean and comfortable?

Yes
No

Comments:

7) How would you rate the Technician's explanation of the MRI process?

Very Satisfied
Satisfied
Somewhat Satisfied
Dissatisfied

Comments:

8) Would you recommend Crossroads MRI to a friend or family member?

Definitely would
Might recommend
Would not recommend

Comments:

Additional Comments:

Although it is not required, if you have any comments that you would allow us to use in our promotional advertising, please type "Yes" or "No" the box below and type your full name.

, I hereby authorize the use of the above information along with the use of my name by Crossroads MRI for promotional advertising.

Full name:    Date:

Thank you for completing our survey. We appreciate your business.