Patient Survey Form

Your impression of our facility is important to us. Please use this form to complete our survey online. Information passed via this form is securley submitted to our office. We appreciate your time in communicating your experience and value your opinion.


How did you hear about Peninsula Imaging?
My Doctor Friend or Relative Radio Metropolitian Magazine
Local Book Yellow Pages Print Advertisement Internet

YesNo
Scheduling my appointment was easy and convenient -    
The office staff was courteous and informative -    
The waiting area was clean and comfortable -    
The procedure was performed in a timely manner -    
My overall experience was positive, I would recommend Peninsula Imaging to friends and family -    

To better serve you, if you marked No for any of these questions, could you provide additional information below?



First Name (optional):
Last Name (optional):
Your E-mail (optional):
Your Phone # (optional):
May we use your name and comments in our marketing materials? YesNo