Please rate us in the following areas:

1. Cleanliness and overall atmosphere of the center:
   Excellent   Good   Average   Fair   Poor

2. Helpfulness and friendliness of our clerical staff (receptionist, scheduling, billing):
   Excellent   Good   Average   Fair   Poor

3. Helpfulness and friendliness of our technical staff (technologist, radiologist):
   Excellent   Good   Average   Fair   Poor

4. Were you seen on or close to your appointment time?
   Yes   No      How long past?

5. How would you rate your overall experience at our center?
   Excellent   Good   Average   Fair   Poor

6. Would you recommend Phoenix Diagnostic Imaging to others?
   Yes   No

7. How did you hear about Phoenix Diagnostic Imaging?
   Physician referral   Internet   Newspaper/article   Phone book   Sign   Mailer   Health fair
   Other   If Other:

8. Was there anything that you particularly liked or disliked about our center or experience?


9. Who is your insurance provider?

10. May we share your comments with your physician or your insurance company?
   Yes   No

Thank you for your input!

Patient Name:

Patient Email:

Address:     City:     State:     Zip:

Physician's Name:

Date:     Scan Type:

Arrival Time:     Scheduled Time:     Table Time:     End Time: