Patient Satisfaction Survey

How would you rate your scheduling experience?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
When you arrived for your appointment, were you seen at your scheduled time?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
When you arrived for your appointment, were you greeted in a friendly manner by the front desk?
Yes
No
Did the technologist performing your exam introduce his/herself?
Yes
No
Did the technologist explain your exam to you?
Yes
No
Did you feel you were treated in a polite and professional manner?
Yes
No
Was the office neat and clean?
Yes
No
How would you rate the parking experience?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
N/A
Comments
How would you rate your waiting room experience?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
N/A
How would you rate your overall experience at CMI?
Very Satisfied
Somewhat Satisfied
Neutral
Somewhat Dissatisfied
Very Dissatisfied
N/A
Have you visited our website prior to your appointment?
Yes
No
Have you heard our radio ad with Dr. John Picano?
Yes
No
Was this your first visit as a patient to CMI? Yes/No
Yes
No
Which location did you visit?
Was there anything we could do to make your experience with us better?
Name / Address (Optional):

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