We are committed to ensuring that you are satisfied with the care and services you receive at our practice. Please let us know what you think about your experience with us.

Patient Satisfaction Survey

1. Date of your appointment*

2. Type of Exam:

 MRI Ultrasound X-Ray Mammogram CT Vascular Bone Density
Other:

3. Physician/provider that ordered exam?

4. Please rate the ease in scheduling your appointment:

Difficult 1 2 3 4 5   Easy

5. How long did it take from your appointment time until you were taken in for your exam?

 0-10 min 11-20 min More than 20 min

Please rate the quality of service you received:

6. Registration desk personnel

Poor  1 2 3 4 5   Excellent

7. Technologist performing your exam

Poor  1 2 3 4 5   Excellent

8. How would you rate your overall experience at SFI?

Poor  1 2 3 4 5   Excellent

9. Would you recommend SFI to friends and family?

 Yes No
If no, why not?

10. Comments

Optional

11. Name

12. May we use your testimonial?

 Yes No

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