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Type of imaging service you recieved?
X-Ray
Ultrasound
CT
MRI
Mammography
Nuclear Medicine
Bone Mineral Density
Interventional procedures
Dental Imaging
Other
Name of imaging staff who attended you today?
Very Dissatisfied
Not Satisfied
Neutral
Satisfied
Very Satisfied
How would you rate our booking service?
-
Comments:
Please tell us how long you waited in reception before your examination?
<5min
5-10 Min
10-15 Min
15-20 Min
20-30 Min
over 30 Min
How satisfied are you with the following:
Very Dissatisfied
Very Satisfied
*
Please rate your overall experience:
-
Comments/Suggestions:
Please specify how we can improve our service?
How did you hear about us?
GP
Specialist
Website
Billboard
Signs
Word of mouth
Magazine
Radio
TV
Other
Date you received imaging service?
Month
Day
Year
--
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
--
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
--
2016
Age Range?
Less than 20?
20 - 30
30 - 40
40 - 50
50 -60
60 - 70
over 80
Your gender
Female
Male
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