Patient Feedback Form

Purpose of Visit: Ultrasound
Mammography
X-Ray
Barium Enema
Bone Mineral Density

Were we easy to find? Yes No

Were you registered promptly? Yes No

Was the waiting time acceptable? Yes No

If not how long did you wait?

Did you have an appointment? Yes No

Were you treated in courteous and prefessional manner by the receptionist? Yes No

Were you treated in courteous and prefessional manner by the technologist? Yes No

Were you treated in courteous and prefessional manner by the physician? Yes No

Was the waiting room clean & orderly? Yes No

Was the washroom clean and tidy? Yes No

Are the hours convenient? Yes No

What could we have done better?

Comments:*

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