Patient Satisfaction Survey

As part of Quakerbridge Radiology Associates commitment to patient satisfaction, we are seeking your evaluation of your experience with our facility. We appreciate your feedback in helping Quakerbridge Radiology Associates improve our facility, services and marketing efforts.

First Name: Last Name: Primary Phone Number: Secondary Phone Number: * Why did you choose Quakerbridge Radiology Associates? Doctor's Office Previous Patient Advertising Other: Have you seen our advertising? RWJ Hospital Guide Trenton Times Hamilton Post Phone Book AMC 24 Hamilton Movies UA Marketfair 10 Movies Mercer Woman Sovereign Bank Arena Section 106/107 Community Event / Health Fair Other:

Evaluation of Quality of Service

1. Were we accommodating in helping you set-up your appointment? Strongly Agree Agree Disagree Strongly Disagree
2. Did you receive helpful service at the front desk? Strongly Agree Agree Disagree Strongly Disagree
3. Were you pleased with how the technologist performed your study? Strongly Agree Agree Disagree Strongly Disagree
4. When your study was complete were you walked back to the front desk and treated in a courteous manner? Strongly Agree Agree Disagree Strongly Disagree
5. Do you wish to be contacted by management to discuss any issues or concerns? Yes No
6. Would you like to enter the free monthly drawing for a $50 gift certificate? Yes No
7. Would you be interested in providing a customer testimonial? Yes
   No
8. Is there anyone you'd like to commend on a job well done? *
9. Are there any additional comments you would like to make about our facility and/or personnel? *
   Please note that all comments are held in the strictest confidence with upper management.

* denotes optional form field