Patient Survey You must have JavaScript enabled to use this form. Thank you for providing us feedback about your experience. Some patients may receive a Press Ganey survey in the mail or by email. The Press Ganey survey compares our imaging center to different imaging centers nationally. The online survey below is a separate tool that also helps us improve patient care. Your comments and suggestions help us to do our best in our mission to provide excellence in care for each patient. Your information is confidential. We do not share your email or information. Patient Name Name of Referring Provider or Practice Type of Exam(s) CT MRI / MRA Ultrasound X-ray Screening Mammogram Diagnostic Mammogram DEXA (Bone Density) Fluoroscopy Other (please specify) Other: Date of Exam Year Year20222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Location where you had your exam: Robinwood Professional Center (Suite 204) Robinwood Professional Center (Suite 222) Women's Imagining Center Hub Plaza Professional Court Appointment Scheduling Convenience 1 = Poor | 5 = Excellent 1 2 3 4 5 Professionalism 1 = Poor | 5 = Excellent 1 2 3 4 5 Met Your Needs 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Imaging Center Comfort 1 = Poor | 5 = Excellent 1 2 3 4 5 Location 1 = Poor | 5 = Excellent 1 2 3 4 5 Cleanliness 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Front Desk Personnel Professionalism 1 = Poor | 5 = Excellent 1 2 3 4 5 Answered Your Questions 1 = Poor | 5 = Excellent 1 2 3 4 5 Met Your Needs 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Technologist / Exam Experience Promptness 1 = Poor | 5 = Excellent 1 2 3 4 5 Friendliness 1 = Poor | 5 = Excellent 1 2 3 4 5 Knowledgeable 1 = Poor | 5 = Excellent 1 2 3 4 5 Answered Your Questions 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Employee or Staff you would like to mention or recognize (and why) Why did you choose our imaging center? (check all that apply) Convenient location Physician referral Reputation Previous visit Insurance referral Advertising Other (please specify) Other: Would you recommend this facility to a friend or family member? Yes No Comments: Comments: Any other comments or concerns? Would you like someone to contact you about any of your concerns? Yes (I have included my contact information below) No thank you Comments: Comments:
You must have JavaScript enabled to use this form. Thank you for providing us feedback about your experience. Some patients may receive a Press Ganey survey in the mail or by email. The Press Ganey survey compares our imaging center to different imaging centers nationally. The online survey below is a separate tool that also helps us improve patient care. Your comments and suggestions help us to do our best in our mission to provide excellence in care for each patient. Your information is confidential. We do not share your email or information. Patient Name Name of Referring Provider or Practice Type of Exam(s) CT MRI / MRA Ultrasound X-ray Screening Mammogram Diagnostic Mammogram DEXA (Bone Density) Fluoroscopy Other (please specify) Other: Date of Exam Year Year20222023 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Location where you had your exam: Robinwood Professional Center (Suite 204) Robinwood Professional Center (Suite 222) Women's Imagining Center Hub Plaza Professional Court Appointment Scheduling Convenience 1 = Poor | 5 = Excellent 1 2 3 4 5 Professionalism 1 = Poor | 5 = Excellent 1 2 3 4 5 Met Your Needs 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Imaging Center Comfort 1 = Poor | 5 = Excellent 1 2 3 4 5 Location 1 = Poor | 5 = Excellent 1 2 3 4 5 Cleanliness 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Front Desk Personnel Professionalism 1 = Poor | 5 = Excellent 1 2 3 4 5 Answered Your Questions 1 = Poor | 5 = Excellent 1 2 3 4 5 Met Your Needs 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Technologist / Exam Experience Promptness 1 = Poor | 5 = Excellent 1 2 3 4 5 Friendliness 1 = Poor | 5 = Excellent 1 2 3 4 5 Knowledgeable 1 = Poor | 5 = Excellent 1 2 3 4 5 Answered Your Questions 1 = Poor | 5 = Excellent 1 2 3 4 5 Comments: Comments: Employee or Staff you would like to mention or recognize (and why) Why did you choose our imaging center? (check all that apply) Convenient location Physician referral Reputation Previous visit Insurance referral Advertising Other (please specify) Other: Would you recommend this facility to a friend or family member? Yes No Comments: Comments: Any other comments or concerns? Would you like someone to contact you about any of your concerns? Yes (I have included my contact information below) No thank you Comments: Comments:
