*Please enter today's date:

Are you claustrophobic?--YesNo

Have you had a previous MRI?--YesNo

If yes, what type of MRI unit was it?--Regular Closed MRI UnitOpen MRI UnitUpright or Standup MRI Unit

Were you able to complete the study?--YesNo

How did you hear about Open Upright MRI?--My PhysicianRadio / TV AdvertisementWord of Mouth from a Friend or RelativeNewspaper or MagazineOther

How would you rate your overall experience at Open Upright MRI?--UnpleasantSatisfactoryPleasantExtremely Patient-friendly

Key

1 2 3 4 5 6 7 8 9 10

On a scale of 1 to 10 (1 = worst / 10= best), how would you rate your overall experience in this visit?--12345678910

Your Appointment: The efficiency of the check in--12345678910

Your Appointment: Waiting time in reception area.--12345678910

Our Staff: Friendliness and courtesy of front desk.--12345678910

Our Staff: Care, concern and professionalism of your technologist.--12345678910

Our staff: Explanation of your procedure.--12345678910

How would you compare your Imaging experience at this facility with those that you have had elsewhere?--12345678910

If you needed another MRI in the future, would you consider returning to Open Upright MRI for your study?--12345678910

If a family member or friend needed an MRI would you consider recommending Open Upright MRI to him or her?--12345678910

We at Open Upright MRI are truly interested in always improving the quality of care and attention we can offer our patients. Please share with us your thoughts on what we are doing right, and/or how we can improve our service to our patients:

Were you aware that Open Upright MRI is the only Upright Open MRI in the state of Alabama? --YesNo

May we use you for a reference? --YesNo

Your name: (OPTIONAL)