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infertility clinic Mississauga, Brampton, Bolton, Milton
 
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Patient Evaluation Form

We would like to know how we are doing. We strive to improve your care. Your concerns or suggestions are very important to us.

1) How did you know about us?

Family doctor referral
Family/ Friend
Internet
Yellow Pages
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Other

2) If you have been with Astra for more than one month/cycle, what stage of your management are you at?

3) Did you receive enough information about your treatment?

Yes No

If No, please comment.

4) Did you have a chance to discuss your treatment options, risks benefits and alternatives?

With your DOCTOR?

Yes No

With your NURSE?

Yes No

If No, please comment.

5) Did you feel that your infertility diagnosis was clear and that your management plan addressed your diagnosis?

Yes No

6) Did you find the staff at the clinic accessible (available)?

Yes No

If No, please comment.

7) Did you find the staff supportive and compassionate during your treatment?

Yes No

If No, please comment.

8) Would you recommend us to others?

Yes No

If No, please comment.

9) Based on your experience visiting our clinic, how would you rate the following?

  Poor Fair Satisfactory Good Excellent
Receptionists
Nursing Staff
Ultrasound Technologists
Doctors
Lab Staff
Overall Experience

If you rated anything in the poor, fair or satisfactory rating, please explain your concerns:

Other Suggestions and/or comments

We will use this information to assess and improve our current practices. Your feedback is appreciated. Information submitted will be kept private and confidential. Thank you.

OPTIONAL:

Name:
Phone number:
Email:

Please check box if you would like us to contact you:

 

 
infertility clinics Mississauga, Brampton, Bolton, Milton, Toronto
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