Where did you have your appointment?

What kind of exam did you have?

How did you choose our center?

Would you return to this center?

Please rate the following: (Excellent, Very Good, Good, Fair, Poor)

Was you call answered in a timely manner? (Excellent = 5 and Poor = 1)

If you called or were called to schedule over the phone, how would you rate your experience? (Excellent = 5 and Poor = 1)

Was our receptionist courteous & helpful? (Excellent = 5 and Poor = 1)

Efficiency of the check-in process & paperwork? (Excellent = 5 and Poor = 1)

Courtesy and kindness of our office staff? (Excellent = 5 and Poor = 1)

Comfort and cleanliness of the center? (Excellent = 5 and Poor = 1)

Courtesy and kindness of our technologist(s)? (Excellent = 5 and Poor = 1)

Staff gave a thorough explanation of the services and procedures? (Excellent = 5 and Poor = 1)

Overall quality of care you received? (Excellent = 5 and Poor = 1)

Likelihood that you would recommend us to a friend or relative? (Excellent = 5 and Poor = 1)

Name of Employee(s) who helped you today:

Additional Comments

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