Patient Feedback Survey

We value your opinion. Thank you for your feedback.
Instructions: Complete the questionnaire, then press the submit button at the bottom of this page. Skip any questions that do not apply.


When, where and how did we serve you:

Your date of service: - -

Office you visited:
Reason or procedure:


Rate the following:

Ease of making an appointment when calling by phone. Excellent
Good
Average
Poor
Availability of an appointment within a reasonable time frame. Excellent
Good
Average
Poor
Your treatment by the receptionist. Excellent
Good
Average
Poor
Your treatment by the Technologist (who performed exam). Excellent
Good
Average
Poor
Your treatment by the Radiologist (if you saw one). Excellent
Good
Average
Poor
Our timeliness to receive you. Excellent
Good
Average
Poor
Our timeliness to start exam at scheduled time. Excellent
Good
Average
Poor
Your satisfaction with explanations during and after the exam. Excellent
Good
Average
Poor
The cleanliness of waiting area, dressing rooms and examination areas. Excellent
Good
Average
Poor
Rate the availability of our office hours. Excellent
Good
Average
Poor
Rate your overall experience. Excellent
Good
Average
Poor
How were you referred to (or did you discover) ARS? Physician
Friend
Newspaper
Referring Physician Name (optional):
Last Name First Name
Share any comments, questions or concerns:
Your Name (optional):
Please enter this challenge number in the box below: 808
Press the button below when finished: