X-Ray Service Billing Survey
Please share your feedback about your recent X-ray billing experience to help us improve our services.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Which type of X-ray service did you receive?
*
Please Select
Chest X-ray
Abdominal X-ray
Dental X-ray
Bone/Joint X-ray
Other
How did you receive your bill for the X-ray service?
*
In person at the facility
By email
By postal mail
Online patient portal
Other
Please rate your satisfaction with the following aspects of the billing process:
*
Rows
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
Clarity of charges
1
2
3
4
5
Ease of understanding the bill
6
7
8
9
10
Timeliness of receiving the bill
11
12
13
14
15
Ease of making payment
16
17
18
19
20
Helpfulness of billing staff
21
22
23
24
25
How fair did you find the charges for your X-ray service?
*
Not fair at all
1
2
3
4
Very fair
5
1 is Not fair at all, 5 is Very fair
Did you encounter any issues or problems with your bill?
*
Yes
No
If yes, please describe the issue(s) you encountered.
How likely are you to recommend our X-ray services based on your billing experience?
*
Not likely at all
0
1
2
3
4
5
6
7
8
9
Extremely likely
10
0 is Not likely at all, 10 is Extremely likely
Please provide any suggestions you have to improve our X-ray billing process.
Overall, how would you rate your X-ray billing experience?
*
1
2
3
4
5
Submit Feedback
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