Dear Patient:
We would like to know how we are doing when it comes to meeting your needs. Please complete the enclosed questionnaire and then click the Submit Button. Thank you for your time.
1. When did you visit us? Date Time Choose One 9am 10am 11am 12noon 1pm 2pm 3pm 4pm 5pm
2. Was this your first visit to Greenville Radiology as a patient?
Yes No
3. How / why did you choose Greenville Radiology?
by referral of Doctor because of previous good experience at Greenville Radiology
because of previous bad experience elsewhere
because of recommendations by friend / relative
because of insurance requirements
other; specify
4. What type of procedure(s) did you have at our office?
5. Did our receptionist greet you promptly?
6. Was our receptionist friendly, courteous, and helpful?
7. Were the waiting rooms clean and comfortable?
8. Were you taken on time for your appointment?
Yes No If No, how long did you have to wait?
9. Was the dressing room clean?
10. Once you were prepared / dressed, was your procedure started promptly?
11. Was the technologist . . .
friendly and courteous? Yes No
professional in appearance and conduct? Yes No
careful to explain what she was doing? Yes No
12. Did you see a doctor during your procedure?
Yes No If Yes, was he / she . . .
careful to explain what he / she was doing? Yes No
13. Was the exam room clean?
14. At check out, did the clerk . . .
appear friendly and courteous? Yes No
15. Was there any one thing in particular that you liked about Greenville Radiology?
16. Was there anything you disliked or would like to see changed?
17. Would you like to come back to Greenville Radiology?
18. Do you have any other comments?
19. What overall "grade" would you give Greenville Radiology?
choose one 5-excellent 4-good 3-average 2-fair 1-poor
20. Your name (optional)
Click the Submit Button only once. You should receive a confirmation of your submission in 15-25 seconds. Thank you very much.