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 Durham Diagnostic Imaging to others? Yes No 7. How did you hear about Durham 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: Please enter the characters above for verification purposes:
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