X-ray Exam Assessment Survey
Please help us improve by sharing your feedback on your recent X-ray examination experience.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of X-ray Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of X-ray Exam
*
Please Select
Chest X-ray
Abdominal X-ray
Bone X-ray
Dental X-ray
Other
How did you schedule your X-ray appointment?
Walk-in
Phone call
Online booking
Referred by doctor
Other
Please rate the following aspects of your X-ray exam experience:
*
Rows
Excellent
Good
Fair
Poor
Ease of scheduling
1
2
3
4
Waiting time before exam
5
6
7
8
Staff professionalism
9
10
11
12
Clarity of procedure explanation
13
14
15
16
Comfort during procedure
17
18
19
20
Cleanliness of facility
21
22
23
24
How would you rate your overall satisfaction with your X-ray experience?
*
1
2
3
4
5
Did you experience any discomfort during the X-ray exam?
No discomfort
Mild discomfort
Moderate discomfort
Severe discomfort
Would you recommend our X-ray services to others?
*
Yes
No
Please share any additional comments or suggestions:
Signature (please sign to acknowledge your feedback)
*
Submit Assessment
Submit Assessment
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