| What exam did you have done today? |
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| Have you had a previous: |
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| If yes, to MRI, what type of MRI unit was it? |
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| Are you claustrophobic? |
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| How did you hear about Medica Forsyth Imaging Center? |
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| How would you rate your overall experience at Medica Forsyth Imaging Center? |
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KEY
1 2 3 4
5 6 7 8
9 10
(Worst)
(Best)
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| On a scale of 1 to 10 (1 = worst –
10 = best), how would you rate your overall experience in this visit?
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| Your Appointment: The efficiency of the check-in. |
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| Your Appointment: Waiting time in reception area.
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| Our Staff: Friendliness and courtesy of front desk. |
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| Our Staff: Care, concern and professionalism of your technologist |
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| Our Staff: Explanation of your procedure. |
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| How would you compare your Imaging experience at this
facility with those that you have had elsewhere? |
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| If you needed another MRI in the future, would you consider
returning to Medica Forsyth Open MRI for your study? |
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| If a family member or friend needed
an MRI, CT, US or Dexa Scan, would you consider recommending our facility
to him or her? |
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| We at Medica Forsyth are truly interested
in always improving the quality of care
and attention we can offer our patients.
Please share with us your thoughts on
what we are doing right, and/or how
we can improve our service to our patients: |
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| May we use you for a reference? |
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| Your name: (OPTIONAL) |
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