1. Name (optional)

2. Telephone Number and/or Email Address (optional)

3. Was this your first time visiting Brooklyn Women's Services?

4. Which doctor(s) did you see during your visit?

5. Why did you choose to see this specific doctor?

6. How many minutes did you have to wait to see this doctor?

7. How would you rate your overall experience with the visit to this healthcare professional?

8. Would you return to this healthcare professional (assuming you need future care)?

9. Would you recommend this doctor's services to your family and friends?

10. Did the doctor spend enough time with you during the visit?

11. Did the doctor listen to your explanations and questions carefully?

12. Did the doctor answer your questions thoroughly and properly?

13. Was it easy to schedule your appointment with this doctor?

14. Was the medical office clean in general?

15. How would you rate the medical assistant's friendliness?

16. Was the medical assistant knowledgeable?

17. How would you rate the reception staff's friendliness?

18. How would you rate your overall visit?

19. Please enter below any additional comments you would like to share with us regarding your recent visit.