Patient Satisfaction Survey Question Title * 1. Your Name Question Title * 2. Who was your referring physician? Question Title * 3. Did you have a diagnostic imaging exam at a Radiology Associates covered facility? Yes No If yes, which facility performed your exam? Question Title * 4. How satisfied are you with the service you received at this facility? Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied Question Title * 5. How satisfied are you with the service you received from Radiology Associates? Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied Question Title * 6. Is there anything Radiology Associates can do to improve the service offered to our patients? Question Title * 7. Do you have any additional comments for Radiology Associates? Question Title * 8. Would you like someone from Radiology Associates to contact you to discuss your experience? Yes No Phone Number or E-mail Done
