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The Center For Advanced Imaging : Physicians and Medical Professionals

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Administration

	Martin Hellkamp President martin@caimri.com
	Paul Hellkamp COO paul@caimri.com
	Luci MacCormack Director of Physician Relations luci@caimri.com
	Center for Advanced Imaging 2923 Franklin Street, Roanoke VA 24014 T- 540-581-0882 F- 540-581-0881

Questionnaire for Referring Nurses

This questionnaire is designed to assess the quality of imaging services provided to you. We would appreciate your comments, both positive and negative, which might help us in our continuing efforts to assure the quality of Imaging services and patient care.

For the following questions, please indicate your degree of satisfaction by checking the appropriate number, with 1 indicating "not satisfied" and 5 indicating "very satisfied".

1. Reception
A. Overall Professionalism	1 2 3 4 5
B. Short hold times (phone)	1 2 3 4 5
C. Phone Hospitality	1 2 3 4 5
D. Competency	1 2 3 4 5
Comments
2. Department Operations
A. Ease of obtaining telephone/fax reports	1 2 3 4 5
B. Ease of sending telephone/fax orders	1 2 3 4 5
C. Quick patient turn around times	1 2 3 4 5
Comments
3. Physical Facilities (Personal Experience/Patient Feedback)
A. Easy access	1 2 3 4 5
B. Comfortable	1 2 3 4 5
C. Clean	1 2 3 4 5
D. Aesthetically pleasing	1 2 3 4 5
Comments
4. Radiology Staff
A. Professionalism	1 2 3 4 5
B. Interaction/feedback from patients	1 2 3 4 5
C. Cooperation with your office staff	1 2 3 4 5
D. Availability for Questions	1 2 3 4 5
Comments
5. Overall Customer Service
A. Patient Care	1 2 3 4 5
B. Staffing	1 2 3 4 5
C. Cooperation with your office staff	1 2 3 4 5
D. Responsiveness to problems/complaints	1 2 3 4 5
E. Ability to solve problems/complaints	1 2 3 4 5
Comments

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