Patient Feedback Form 1. Which procedure did you have? UltrasoundMammographyBone DensitometryX-Ray 2. Please indicate your level of satisfaction Very Dissatisfied Dissatisfied Satisfied Very Satisfied Appointment Booking Very Dissatisfied Dissatisfied Satisfied Very Satisfied Reception Staff Very Dissatisfied Dissatisfied Satisfied Very Satisfied Technologist Very Dissatisfied Dissatisfied Satisfied Very Satisfied 3. Satisfaction of facility Very Dissatisfied Dissatisfied Satisfied Very Satisfied Cleanliness of waiting room Very Dissatisfied Dissatisfied Satisfied Very Satisfied Cleanliness of exam room Very Dissatisfied Dissatisfied Satisfied Very Satisfied Convenience of hours Very Dissatisfied Dissatisfied Satisfied Very Satisfied Time spent in waiting room Very Dissatisfied Dissatisfied Satisfied Very Satisfied 4. How likely would you recommend ADI? Not at all Neutral Extremely likely Not at all Neutral Extremely likely 5. We appreciate all of our patients experiences. Please let us know how we did, and what we could have done to make the experience better: 6. If you would like us to contact you in regards to your experience, please leave your contact information below: Name* (required): Email* (required): Daytime Phone* (required): Evening Phone* (required):
