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PATIENT EXPERIENCE SURVEY

We’d love to hear what you thought about us.

Date of your visit:
Year
Month
Day
Which services did you use today? (Select all that apply)

Overall Experience

Booking & Scheduling

How easy was it to book your appointment?
Very Easy
Easy
Neutral
Difficult
Very Difficult
Was your appointment time convenient for you?
Yes
No
Somewhat

Wait Times

How would you rate your wait time on the day of your appointment?
Excellent
Good
Fair
Poor
Were you kept informed if there were any delays?
Yes
No
Not Applicable

Staff & Communication

The administrative staff greeted me on arrival and provided prompt assistance.
Yes
No
Somewhat
How would you rate the professionalism and friendliness of our staff?
Excellent
Good
Fair
Poor
Did the technologist explain your procedure clearly?
Yes
No
Somewhat
Did you feel comfortable asking questions?
Yes
No

Clinical Experience

Did you feel well cared for during your imaging exam?
Yes
No
Somewhat
How comfortable was your experience during the procedure?
Very Comfortable
Comfortable
Neutral
Uncomfortable
I felt my privacy was respected throughout my visit.
Yes
No

Facility & Environment

How would you rate the cleanliness of our clinic?
Excellent
Good
Fair
Poor
How would you rate the overall comfort of the clinic environment?
Excellent
Good
Fair
Poor

Results & Follow-up

Was information about your results or next steps clearly explained?
Yes
No
Not Applicable

Final Comments

Would you like to be contacted about your feedback? If yes, please provide your contact information.
Yes
No

Copyright © 2026 Belle River Diagnostic Imaging. All rights reserved.

1679 Essex County Rd 22 Unit 1, Belle River ON N0R 1A0

Tel: 519-727-3993

​

Fax: 519-727-3939

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