| *Please enter in today's date: |
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| Are you claustrophobic? |
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| Have you had a previous MRI? |
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| If yes, what type of MRI unit was it? |
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| Were you able to complete the study? |
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| How did you hear about Medica Stand-Up MRI of Birmingham? |
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| How would you rate your overall experience at Medica Stand-Up MRI of Birmingham? |
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KEY
1 2 3 4
5 6 7 8
9 10
(Worst)
(Best)
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| On a scale of 1 to 10 (1 = worst –
10 = best), how would you rate your overall experience in this visit?
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| Your Appointment: The efficiency of the check-in. |
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| Your Appointment: Waiting time in reception area.
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| Our Staff: Friendliness and courtesy of front desk. |
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| Our Staff: Care, concern and professionalism of your technologist |
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| Our Staff: Explanation of your procedure. |
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| How would you compare your Imaging experience at this
facility with those that you have had elsewhere? |
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| If you needed another MRI in the future, would you consider
returning to Medica Stand-Up MRI of Birmingham for your study? |
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| If a family member or friend needed
an MRI would you consider recommending Medica Stand-Up
MRI of Birmingham to him or her? |
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| We at Medica Stand-Up MRI of Birmingham are truly interested
in always improving the quality of care
and attention we can offer our patients.
Please share with us your thoughts on
what we are doing right, and/or how
we can improve our service to our patients: |
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| Were you aware that Medica Stand-Up
MRI of Birmingham is the only Upright® Open MRI in the state of Alabama? |
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| May we use you for a reference? |
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| Your name: (OPTIONAL) |
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