(805) 286-4617
About Us
Our Locations
Templeton
Pismo Beach
Santa Maria
Services
Our Doctors
Patient Resources
Make an Appointment
Patient Forms
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Health Companion
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Glossary Of Terms
Physician Resources
Radiologist Schedule
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Contact
Patient Survey
Where did you have your appointment?
DMI - Santa Maria
RDC - Templeton
FCMI - Pismo Beach
What type of exam did you have?
X-Ray
MRI
Mammogram
PET
CT
Ultrasound
DEXA
Other
How did you choose our center?
Newspaper/Magazine
Radio/TV
Physician/Referral
Friend/Family
Other
Would you return to this center?
Yes
No
Please rate the following:
Was your call answered in a timely manner? (Excellent = 5 and Poor = 1)
5
4
3
2
1
If you called or were called to schedule over the phone, how would you rate your experience? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Was our receptionist courteous & helpful? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Efficiency of the check-in process & paperwork? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Courtesy and kindness of our office staff? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Comfort and cleanliness of the center? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Courtesy and kindness of our technologist(s)? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Staff gave a thorough explanation of the services and procedures? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Overall quality of care you received? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Likelihood that you would recommend us to a friend or relative? (Excellent = 5 and Poor = 1)
5
4
3
2
1
Name of Employee(s) who helped you today:
Employee Name 1
Employee Name 2
Additional Comments
May we contact you regarding your comments?
yes
no
Full Name
Address
Email or Phone
