In our effort to provide the best possible service to the patients who are referred to us, we would appreciate your comments regarding your recent visit to our facility. Please complete this short questionaire and submit it to us. Thank you for your help in improving our service.
At which Open MRI facility did you have your MRI done?	Please Select St. Charles County St. Louis
Name of physician who referred you:
How would you rate the greeting you received?	Please Select 1-Poor 2-Fair 3-Good 4-Very Good 5-Superior
Was your test started in a timely manner?	Please Select 1-Poor 2-Fair 3-Good 4-Very Good 5-Superior
Was the test adequately explained to you?	Please Select 1-Poor 2-Fair 3-Good 4-Very Good 5-Superior
Indicate the attitude of the technologist toward you.	Please Select 1-Poor 2-Fair 3-Good 4-Very Good 5-Superior
How would you rate the overall service you received?	Please Select 1-Poor 2-Fair 3-Good 4-Very Good 5-Superior
For future services would you request Open MRI?	Please Select Yes No
How did you hear about Open MRI?	Please Select Physician Insurance Printed Advertisement Radio Advertisement TV Advertisement
We would appreciate any information on our staff or our service, either positive or negative:
Name:
Address:
City, State, Zip
Phone:	- optional
E-Mail