Stand-Up MRI of Deer Park, P.C.

Patient Survey

Patient information-

First name

Middle Initial

Last name

Address

City

Zip

Phone

Please tell us about your visit

Which of our locations did you visit?

Referring Physician name:

Exam performed:

How did you hear about our location?

How long did you have to wait for your exam upon arrival?

Would you use us again or recommend us to a friend?

	Excellent	Above Average	Satisfactory	Below Average	Poor
How would you rate our service overall?

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Our location was convenient and accessible
Our reception area was clean and tidy
Our front office staff was helpful and courteous
Our technologist was helpful and courteous
Our registration process was easy and efficient
The procedure was properly explained to you
Our scheduling procedure and availability met your needs
The billing and collection process was properly explained
Procedure itself went smoothly

Comments:
Thank you for your cooperation. A follow up may be required - if so may we contact you? Yes No

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