Medical Abortion Ultrasound Birth Control Pregnancy Termination Pregnancy Testing Family Planning STD Testing Surgical Abortion 1. Were the instructions you received prior to surgery helpful? Strongly Disagree Disagree Neutral Agree Strongly Agree 2. Were your financial responsibilities discussed and your questions answered? Strongly Disagree Disagree Neutral Agree Strongly Agree 3. Was the waiting time prior to surgery as expected and reasonable? Strongly Disagree Disagree Neutral Agree Strongly Agree 4. Was the facility clean and well kept? Strongly Disagree Disagree Neutral Agree Strongly Agree 5. Was the staff courteous and friendly? Strongly Disagree Disagree Neutral Agree Strongly Agree 6. Was your privacy respected at all times? Strongly Disagree Disagree Neutral Agree Strongly Agree 7. Was your pain level as expected and well controlled? Strongly Disagree Disagree Neutral Agree Strongly Agree 8. Was adequate time allowed for your recovery? Strongly Disagree Disagree Neutral Agree Strongly Agree 9. Were your homecare instructions clear and helpful? Strongly Disagree Disagree Neutral Agree Strongly Agree 10. Did you feel safe at the facility? Strongly Disagree Disagree Neutral Agree Strongly Agree 11. Overall, do you feel you received quality healthcare at the facilities? Strongly Disagree Disagree Neutral Agree Strongly Agree 12. Date of Service 13. Comments Next 14. Date of Birth 15. Patient Name Save Thank You for your Feedback