Date:
Location:

Please rank the following:

Poor

Meets Expectations

Excellent

	1	2	3	4	5
Arranging your procedure
Ease of scheduling
Appointment availibility/convenience
Location and parking
Parking/building access
Directions
Registration
Speed of registration
Reception
The procedure
Information provided about the procedure
Waiting time
Dressing area
Attention to your needs, including pain
Technologist attentive, responsive
Questions answered
Overall Satisfaction

Would you recommend Radia to a collegue, friend or family member?

Yes No

Do you have any suggestions for us?

Would you like us to contact you?

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