Confidential Patient Survey

We are committed to providing the best imaging service possible. We value your feedback and perspective. Thank you for taking the time to make your comments available to us and for allowing us to serve you.

Name:

Date of Exam: *

Facility

1 = Poor, 4 = Excellent

Cleanliness, comfort, location / access: *

Appointment scheduling

1 = Poor, 4 = Excellent

Convenience, professionalism, met your needs: *

Front desk personnel

1 = Poor, 4 = Excellent

Promptness, friendliness, appearance, knowledge: *

Employee name: *

Why did you choose our imaging center?: *

Convenient location

Previous visit

Advertising

Insurance referral

Physician referral

Reputation

Other

Comments:

For additional questions, concerns or comments, please call (805) 778-1513 or click here