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.
  • MM slash DD slash YYYY
  • Please rate the importance of each of the following:

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.