Patient Evaluation Form

All responses to the following Patient Evaluation form will be kept confidential.

Metropolitan Family Planning Clinic wants to know how you feel about the services we provided so we can make sure we are meeting all of our patient’s needs. Your responses are directly responsible for improving our services going forward.

Thank you for your time and for submitting the valuable Patient Evaluation form.

Patient Evaluation

The (*) indicates that the field must be completed on the Patient Evaluation form below. Your valuable feedback helps us improve our services at Metropolitan Family Planning.

Which location did you receive services?*
Type of service you received at Metropolitan Family Planning*
Type of service you received at Metropolitan Family Planning*
Date of Service*
MM slash DD slash YYYY
How do you think we are doing?*
Ability to get in for an appointment*
The responsiveness and politeness shown by our front desk?*
Amount of time our counselor spent with you?*
Professionalism and knowledge of our counselor*
Was the exam room and/or surgical room neat and clean?*
Overall care provided to you*
Keeping my personal information PRIVATE*
Please rate the importance of each of the following:
Courtesy*
Fees*
Number of Services Provided*
Would you recommend Metropolitan Family Planning to a friend and/or relative?*
- Yes
- No
- Undecided
Would you like for the administrator to contact you to discuss any concerns or questions?
- Yes
- No
Additional comments:
Name (required if you'd like a call back)
First Last
Phone number (required if you'd like a call back)
Email*
To ensure the validity of this form. Please enter the exact letters and numbers as seen here.

Confidentiality Notice: The information asked online is no different than what you would be asked over the telephone. Your information will be transmitted by secured, encrypted e-mail. Though we make every effort to keep your information secure, it is still possible that the information you provide could be captured by individuals who are engaged in illegal internet observance. By providing and submitting your confidential information, you accept the risk of sending this information by e-mail to Metropolitan Family Planning’s personnel. When submitting by e-mail, you also agree not to hold Metropolitan Family Planning, including its employees and agents, liable for any damages you may incur as a result of this transfer or use of this information.

“I came in not knowing what to expect, embarrassed and afraid but those feelings subsided all due to the wonderful bedside manners provided by you and your supportive staff.”
Patient, Google
"As always Dr Gohari is kind, patient , knowledgeable and has a terrific bedside manner. I frequently recommend him to my friends when I’m asked about my OBGYN!"
Patient, Zocdoc
"I visited this clinic last week for an abortion. From start to finish I felt very comfortable. There were escorts outside to help me in, the waiting area was clean, the staff members were great! Nicole was very kind and willing to listen to me."
Patient, Google
"Very friendly staff, Dr. was great and very thorough with getting any histories the patient has. Made the patient feel comfortable and welcome, very easy to communicate with."
Patient, Zocdoc
"I had an OB/GYN appointment with this practice. It was a great experience the office was very neat and clean. The service that was provided by the medical assistant Miss Nicole was excellent, very compassionate and understand made me feel very comfortable. I will definitely refer my friends and family to this practice. Thank you so much. Keep up the great service."
Patient, Google
"I am beyond appreciative and thankful to them, the services that they offer, and the staff that they have. From start to finish everyone is so naturally welcoming and understanding. No one is forceful or influential and they are very thorough with all of the information and examinations that are given. I felt safe from any harm or judgement at all times and I am forever grateful to everyone!"
Patient, Google
"The doctor was really respectful and communicated with me all the time. He is wonderful I will come back in the future."
Patient, Zocdoc
"Staff was very kind and understanding. I cannot speak for the surgical procedures but if plan c is what you are looking for, this is definitely the place to go."
Patient, Google
"Dr Gohari had great bedside manner and really listened to all my concerns. I left there feeling very confident."
Patient, Zocdoc