Url Patient Survey Form Introduction Gender Male Female Name Phone * Email Address * Date of Exam * Was this your first visit to Affinity Radiology? * First Time Visitor Previous Patient Procedure for which you are providing feedback * -- please select procedure -- MRI PET/CT Digital Mammography Digital X-Ray Ultrasound DEXA (Bone Densitometry) How did you hear about Affinity Radiology? please be specific Advertisement Friend or Family Insurance Plan Internet Search Phone Directory Physician's Office ** Other ** if other, please briefly tell us Rate Us Process of scheduling your appointment Excellent Very Good Good Fair Poor Efficiency of registration process at the front desk Excellent Very Good Good Fair Poor We are committed to providing service in a timely manner. Please rate your wait time Excellent (shorter than expected) Very Good (short wait) Good (reasonable) Fair (longer than expected) Poor (excessively long wait) General appearance and comfort Excellent Very Good Good Fair Poor What level of hospitality did you receive at Affinity Radiology Excellent Very Good Good Fair Poor Overall experience at Affinity Radiology Excellent Very Good Good Fair Poor Would you recommend Affinity Radiology to others? Yes No Please Share It will help us become the best we can be We value employees who make a positive impact in your care. Did any employee(s) exceed your expectations? Please include any names Please share with us any positive comments or areas for improvement
