Patient Satisfaction Survey

Last Name:

1.	Please identify the exam type you had: Mammography Ultrasound Bone Densitometry
1(a).	Please describe how your exam was scheduled: Routine Follow-up Emergency Add-on
2.	Was the appointment date and time convenient to your schedule? Yes No
3.	Was the scheduler informative and pleasant? Yes No
4.	Was the front desk reception staff helpful and pleasant? Yes No
5.	Was the amount of wait time in the reception room acceptable to you? Yes No
6.	Were you satisfied with the sonographer or mammographer that performed your study? Yes No
6 (a).	Were all of your medical questions and concerns answered? Yes No
7.	If you spoke with the billing staff, were they helpful and pleasant? Yes No
8.	Was the overall appearance of the office, reception area and exam room clean and neat? Yes No
9.	Would you recommend Ultrasound Associates to a relative or friend? Yes No
10.	Overall, how would you rate our practice? Excellent Good Fair Poor
Comments:
I would like to be contacted. Yes No

Name:
Telephone Number:
Best Time to Call:

Accredited By:
The American Institute of Ultrasound in Medicine (AIUM); Obstetric, Gynecologic, Abdominal, and General Ultrasound
The American College of Radiology (ACR); Obstetric, Gynecologic, and General Ultrasound
The Fetal Medicine Foundation: Nuchal Translucency, Prenatal Screening

Patient Satisfaction Survey

For Patients

For Physicians

Ultrasound

Mammography

Bone Densitometry

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