Outpatient Radiology Service Feedback Form

Date of Visit

Patient Name (Optional)

Email Address (Optional)

Service Experience

Ease of Scheduling Appointment

Excellent Good Fair Poor

Courtesy of Staff

Excellent Good Fair Poor

Waiting Time

Very Satisfied Satisfied Neutral Dissatisfied

Facility Cleanliness

Radiology Staff

Professionalism of Radiology Technician

Excellent Good Fair Poor

Explanation of the Procedure

Very Clear Clear Somewhat Clear Unclear

Additional Comments

Suggestions or Comments