Please take a few moments to complete this survey. Its purpose is to evaluate your opinion of our services and to identify areas for improving services. Your contact information is optional.
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NAME
ADDRESS
E-MAIL
E-MAIL 2
PHONE
Purpose of Visit
Ultrasound G.I. X-ray
Mammography Barium Enema Bone Mineral Density
Please rate our services
CONVENIENCE OF LOCATIONS
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Excellent Good Average Below Average Poor Not Applicable
SPEED OF SERVICE
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STAFF COURTESY - RECEPTIONIST
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STAFF COURTESY - TECHNOLOGIST
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STAFF COURTESY - PHYSICIAN
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CLEAN & ORDERLY ENVIRONMENT
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OVERALL QUALITY OF SERVICE
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General Comments
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