Radiologic Associates of Fredericksburg Survey

Date of visit..........

 
 

50 characters left.

Which location did you visit.........

 
Mary Washington Hospital
Medical Imaging of Fredericksburg
Imaging Center for Women
Medical Imaging at Lee's Hill
Medical Imaging of North Stafford
Stafford Hospital

Patient's first visit to this facility?

 
Yes
No

Patient's sex..........

 
Male
Female

Patient's age..........

 
 

50 characters left.

On what day was your most recent visit?

 
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

At what time of day was your most recent visit?

 
6:00am-8:00am
8:01am-10:00am
10:01am-Noon
12:01pm-2:00pm
2:01pm-4:00pm
4:01pm-6:00pm
6:01pm-8:00pm
8:01pm-10:00pm

Type of service/procedure experienced..........

 
MRI
Xray
Fluoroscopy
Ultrasound
CT Scan
Imaging Center for Women
Nuclear Medicine
Interventional Radiology
Vascular Surgery
PET/CT Scan

INSTRUCTIONS:  Please rate the outpatient service you received from our facility.  Rate only the service/procedure identified above.  Please select the rating that best describes your experience.  If a question does not apply to you, please skip to the next question.  Space is provided for your comments.

 
 

REGISTRATION

1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good

 
 1 2 3 4 5 
Helpfulness of the person at the registration desk
Ease of the registration process
Wait time in registration
  • Comment:

  • 500 characters left.

FACILITY

1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good

 
 1 2 3 4 5 
Comfort of the waiting area
Ease of finding your way around
Cleanliness of the facility
Ease of finding the facility
  • Comment:

  • 500 characters left.

YOUR TEST OR TREATMENT

1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good

 
 1 2 3 4 5 
Friendliness/courtesy of the staff who provided your test or treatment
Explanations from the staff about your test or treatment
Skill of the staff who provided your test or treatment
Staff's concern for your comfort
Staff's concern for your questions or worries
  • Comment:

  • 500 characters left.

PERSONAL ISSUES

1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good

 
 1 2 3 4 5 
Staff's concern for your privacy
Staff's sensitivity to your needs
Response to concerns/complaints made during your visit
  • Comment:

  • 500 characters left.

OVERALL ASSESSMENT

1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = very good

 
 1 2 3 4 5 
How well staff worked together to provide care
Overall rating of care received during your visit
Likelihood of your recommending our facility to others
  • Comment:

  • 500 characters left.

Patient's Name:  (optional)

 
 

50 characters left.

Telephone Number:  (optional)

 
 

50 characters left.

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First Name:
Last Name:
Email Address:
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