X-RAY ASSOCIATES PATIENT SURVEY

Please let us know about your patient experience at any of our X-ray Associates Clinics.

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* 1. Type of Service Provided

X-Ray

Ultrasound

BMD

Nuclear Medicine

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* 2. Please provide the name of the staff member, so that we can follow up

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* 3. Date of Service Provided

Date / Time

Date

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* 4. Which X-Ray Associates location did you receive the indicated services from

679 Davis Drive., Newmarket

250 Harding Blvd., Richmond Hill

125 Pedersen Drive., Aurora

955 Major Mackenzie Dr., Vaughan

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* 5. Please rate each item by selecting the rating that best describes your opinion. Please complete all fields prior to submitting

	Poor	Good	Excellent	N/A
Waiting time: How long you had to wait to get an appointment at this clinic	Waiting time: How long you had to wait to get an appointment at this clinic Poor	Waiting time: How long you had to wait to get an appointment at this clinic Good	Waiting time: How long you had to wait to get an appointment at this clinic Excellent	Waiting time: How long you had to wait to get an appointment at this clinic N/A
Waiting time: How was the length of time before you were seen?	Waiting time: How was the length of time before you were seen? Poor	Waiting time: How was the length of time before you were seen? Good	Waiting time: How was the length of time before you were seen? Excellent	Waiting time: How was the length of time before you were seen? N/A
Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff Poor	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff Good	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff Excellent	Instructions: How well and how clearly were your preparations for the test explained to you by the clinic staff N/A
Ease of getting information: Willingness of the clinic staff to answer questions	Ease of getting information: Willingness of the clinic staff to answer questions Poor	Ease of getting information: Willingness of the clinic staff to answer questions Good	Ease of getting information: Willingness of the clinic staff to answer questions Excellent	Ease of getting information: Willingness of the clinic staff to answer questions N/A
Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests Poor	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests Good	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests Excellent	Information you were given: How clearly and completely were the explanations of any possible risks and complications of tests N/A
Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness)	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) Poor	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) Good	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) Excellent	Overall treatment: How well did the staff listen and understand what was important to you (e.g. Concern, care, respect, friendliness, kindness) N/A
Safety and Security: How well did the staff provide for the safety and security of your belongings	Safety and Security: How well did the staff provide for the safety and security of your belongings Poor	Safety and Security: How well did the staff provide for the safety and security of your belongings Good	Safety and Security: How well did the staff provide for the safety and security of your belongings Excellent	Safety and Security: How well did the staff provide for the safety and security of your belongings N/A
Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing)	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) Poor	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) Good	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) Excellent	Privacy: How well was your privacy considered (e.g. type of gowns used, privacy while changing) N/A
Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic Poor	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic Good	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic Excellent	Instructions on leaving: How clearly and completely were you told of what to do and what to expect after you have left the clinic N/A
Overall quality of care: How would you evaluate the services and the treatment you received in this clinic	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic Poor	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic Good	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic Excellent	Overall quality of care: How would you evaluate the services and the treatment you received in this clinic N/A
Cleanliness of the Facility: How clean was the facility	Cleanliness of the Facility: How clean was the facility Poor	Cleanliness of the Facility: How clean was the facility Good	Cleanliness of the Facility: How clean was the facility Excellent	Cleanliness of the Facility: How clean was the facility N/A

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* 6. Would you recommend this clinic to a friend or family member if they needed the services of this clinic

Yes

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* 7. What suggestions or changes would you recommend to improve our service?

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* 8. If you would like to be contacted about your concerns please add your name and telephone number

Full Name

Phone Number

X-RAY ASSOCIATES PATIENT SURVEY

We appreciate your Feedback!

Question Title

* 1. Type of Service Provided

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* 2. Please provide the name of the staff member, so that we can follow up

Question Title

* 3. Date of Service Provided

Question Title

* 4. Which X-Ray Associates location did you receive the indicated services from

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* 5. Please rate each item by selecting the rating that best describes your opinion. Please complete all fields prior to submitting

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* 6. Would you recommend this clinic to a friend or family member if they needed the services of this clinic

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* 7. What suggestions or changes would you recommend to improve our service?

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* 8. If you would like to be contacted about your concerns please add your name and telephone number