Patient Survey - Santa Fe Imaging

Name *

Date of Birth *//

Email *

Phone *

No hyphens

Type of Exam *

Please check all that apply. Please note all XRAY exams are walk-ins. If scheduling for mammogram, ask about same or next day appointments.

Please Specify Exam Needed *

Has Your Provider Ordered Your Exam *

Yes
No

PLEASE NOTE THAT IF YOUR PROVIDER HAS NOT FAXED, EMAILED, OR ELECTRONICALLY ORDERED YOUR EXAM, THEN WE CANNOT SCHEDULE YOUR APPOINTMENT

Who Ordered Your Exam *

Please enter name of provider who ordered your exam

Message

**NOTE: IF YOU HAVE EVER HAD PRIOR IMAGING DONE FOR THE CURRENT BODY PART, WE WILL NEED THOSE IMAGES FOR COMPARISON. WITHOUT THOSE IMAGES, THERE COULD BE A DELAY IN REPORTING YOUR EXAM.