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Dear Valued Patient,

At NewLife Fertility an integrated team is at your service, including physicians, nurses, embryologists and a compassionate counsellor. You receive a personalized program of education, counselling, and medical treatment in a caring and respectful setting.

If you have any questions you would like answered, one of our physicians will direct your care, with the support of other members of our team andwill be more than happy to help you.

Please take a few moments to fill this form out.

 

Please take a moment to fill this form.

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 NewLife Fertility for more than one month/cycle, what stage of your management are you at?
( look in the drop box, please add all the words)

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:

 
Security Code:

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

   

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