Services Birth Control Pregnancy Termination Pregnancy Testing Family Planning Surgical Abortion Medical Abortion Vasectomy Ultrasound1. Were the instructions you received prior to surgery helpful? Strongly Disagree Disagree Neutral Agree Strongly Agree2. Were your financial responsibilities discussed and your questions answered? Strongly Disagree Disagree Neutral Agree Strongly Agree3. Was the waiting time prior to surgery as expected and reasonable? Strongly Disagree Disagree Neutral Agree Strongly Agree4. Was the facility clean and well kept? Strongly Disagree Disagree Neutral Agree Strongly Agree5. Was the staff courteous and friendly? Strongly Disagree Disagree Neutral Agree Strongly Agree6. Was your privacy respected at all times? Strongly Disagree Disagree Neutral Agree Strongly Agree7. Was your pain level as expected and well controlled? Strongly Disagree Disagree Neutral Agree Strongly Agree8. Was adequate time allowed for your recovery? Strongly Disagree Disagree Neutral Agree Strongly Agree9. Were your homecare instructions clear and helpful? Strongly Disagree Disagree Neutral Agree Strongly Agree10. Did you feel safe at the facility? Strongly Disagree Disagree Neutral Agree Strongly Agree11. Overall, do you feel you received quality healthcare at the facilities? Strongly Disagree Disagree Neutral Agree Strongly Agree12. Date of Service 13. CommentsNext14. Date of Birth 15. Patient NameSaveThank You for your Feedback