Patient Survey Card

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Thank you for visiting our facility today. Please feel free to share with us any comments that will help us continually exceed your expectations. Thank you for your feedback.

For each item identified below, fill in the number in the circle that best fits your judgment of its quality. Using the rating scale to select the quality number with 1 being the worst and 5 being the best.

Worst Best

Were you able to make an appointment quickly and easily?...............12345

Was the scheduling staff friendly, knowledgeable & helpful?..............12345

Upon arrival, was the registration performed quickly and efficiently?....12345

How thoroughly was your procedure explained to you?......................12345

Do you feel your exam was performed professionally?........................12345

If you met with a radiologist, was she/he polite and informative?.........12345

Overall, did you find our staff friendly, courteous and attentive?..........12345

How would you rate the comfort of the surroundings?........................12345

Overall, how would you rate the quality of care you received?.............12345

How would you rate your total visit time?........................................12345

How would you rate the cleanliness of our facility?............................12345

Exam

Is there someone you would like to recognize for outstanding service or patient care?

Additional Comments

First Name

Last Name

Date of Birth

Date of Exam

Location of Exam

Windsong Office Location (Required)

Would you like someone to contact you?..............YESNO

Daytime Phone Number

Your Email

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