Register to Win
Please fill out the registration form below and you will be entered in a drawing for your chance to win maid service for a day by American Maid Service. The last day to enter the drawing is June 15, 2010.
Registration Information *Name: Address: City, State, Zip: Phone Number: *Email: Gender: Male Female Age: Under 30 30-40 40-50 Over 50 Do you make most of the health care decisions in your family? Yes No Did you know you had a choice in choosing your diagnostic imaging facility? Yes No Would you ask your doctor to go to the Imaging Center? Yes No If you are a female over the age of 40, have you had a regular mammogram screening? Yes No * Required field - Please make sure you have a name and valid email address before you hit the submit button. Only one entry per household. Must be 18 to win. Imaging Center employees not eligible to win.
Registration Information
Male Female
Age:
Under 30 30-40 40-50 Over 50
Do you make most of the health care decisions in your family?
Yes No
Did you know you had a choice in choosing your diagnostic imaging facility?
* Required field - Please make sure you have a name and valid email address before you hit the submit button. Only one entry per household. Must be 18 to win. Imaging Center employees not eligible to win.
