We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services and you can enter as much information as you want. All responses will be kept Confidential. Thank you for your time.
What type of service did you receive? First Trimester Surgical Abortion Second Trimester Surgical Abortion Non-surgical Abortion Pregnancy Testing STD Testing Pap Smear *
Date of Service ... *
How do you think we are doing? Great Good Needs Improving
Ability to get in for an appointment at our center? Great Good Needs Improving *
How was the patient representative who made your appointment? Great Good Needs Improving
The responsiveness and politeness show by our front desk? Great Good Needs Improving
The amount of time our treatment coordinator spent with you? Great Good Needs Improving
The professionalism of our treatment coordinator? Great Good Needs Improving
Did the clinician answer your questions? Great Good Needs Improving
Was the exam room and/or surgical suites neat and clean? Great Good Needs Improving
Did the nurse listen to your requests? Great Good Needs Improving
The overall care provided to you? Great Good Needs Improving
Keeping my personal information private? Great Good Needs Improving
Courtesy Very Important Indifferent Not Important
Price Very Important Indifferent Not Important
Would you recommend Birth Control Care Center to a friend and/or relative? Yes No *
What did you like best about our center?
What did you like least about our center?
Would you like a manager to contact you to discuss any concerns or questions? Yes No
First & Last Name (must be provided to validate the legitamcy of this feedback form - Strictly Confidential) *
Phone Number (if you wish to be contacted)
Enter the numbers and letters you see on the right
Thank you for your feedback.
