Thank-you for choosing Southeastern Med as your Imaging Service.  In an effort to understand and meet our patient’s needs, we would like for you to fill out the following survey.  Thank-you in advance for helping us to improve our patient care.

Please check the appropriate response to each question.

                           Area of testing:           X-ray    Cat-Scan    MRI     Ultrasound  
                          Nuclear Medicine       Mammography       
                         Angiography (arteriography)

Time of Service         am                       pm

Yes      No

              1.  Did the transporter introduce themselves to you?

              2.  Were you treated in a warm friendly manner?

              3.  Were you transported in a safe manner?

              5.  Was your exam explained to you, prior to your test by your doctor?

              6.  Did the technologist explain your exam to you?

              7.  Was your test done in a timely manner?

              8.  If no, was there an explanation offered for the delay?

              9.  Were the room conditions comfortable and clean?

            10.  Was the technologist or nurse friendly during your exam?

            11. Were you returned to your room in a timely manner?

            12. Would you return to Southeastern Med, for further imaging services?

Additional Comments

Southeastern Med-Diagnostic Imaging Services
Patient Care