Chicago abortion clinics: Family Planning Associates Medical Group abortion clinic

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24 Hour Patient Assistance 877-569-4724
Immediate Appointments Available

Patient Feedback Form

Please fill out the following form

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. All responses will be kept confidential and anonymous. Thank you for your time.

Which Location did you receive services at?:
What type of service did you receive from Family Planning Associates? :
Date of Service:	Pick a date
What is your age? :
How do you think we are doing? :	Very Good Average Needs Improvement NA
Ability to get in for an appointment at this facility? :	Very Good Average Needs Improvement NA
How was the patient representative who made your appointment? :	Very Good Average Needs Improvement NA
The responsiveness and politeness show by our front desk? :	Very Good Average Needs Improvement NA
The amount of time our admitting personnel spent with you? :	Very Good Average Needs Improvement NA
The professionalism of our admitting personnel? :	Very Good Average Needs Improvement NA
Did the clinician answer your questions? :	Very Good Average Needs Improvement NA
Was the exam room and/or surgical suites neat and clean? :	Very Good Average Needs Improvement NA
Did the nurse listen to your requests? :	Very Good Average Needs Improvement NA
The overall care provided to you? :	Very Good Average Needs Improvement NA
Keeping my personal information private? :	Very Good Average Needs Improvement NA
Please rate the importance of each of the following items :
Courtesy:	very important Indifferent Not important
Price:	very important Indifferent Not important
Would you recommend Family Planning Associates Medical Group to a friend and relative? :
What did you like best about our facility? :
What did you like least about our facility?:
Would you like a manager to contact you to discuss any concerns or questions?:	Yes No
The following information is optional, but is required if you wish to be contacted:
Name:
Phone Number to contact you at:
Thank you for the opportunity of providing your women's health care service!