Client Feedback Form

Client Feedback Form
Congratulations on the birth of your baby! I am honored to have been present at such an intimate moment in your life. As part of my ongoing efforts to provide the best service possible, I ask each client to complete a feedback form. This helps me to know where I can improve my service.
Name:
Baby's Date of Birth:
Birth Location:
How did you hear about K4 Birth Services?
What did I do that was most helpful prenatally?
How could I have been more helpful prenatally?
What did I do that was most helpful during your birth?
How could I have been more helpful during your birth?
Did you feel respected during your birth?
What was most helpful postnatally? What could I have done to be more helpful?
Is anything additional you would like to add about your care?
I also ask clients if they would like to share a written birth story with me, if you've written one. If you would like to share, I may publish this on my web site. If you would prefer it to be anonymous, please let me know. A written birth story is a wonderful way of recording your birth as so much of what happens is forgotten over time.

May I use any of your comments/written story from this form and your name on promotional materials, website, etc? If you answer "Yes" please include your name and the date below to give your permission (if at any time you want to withdraw permission, please email me requesting removal).
My comments may be used on promotional materials, website, etc. for K4 Birth Services.

YesNo
Signed Name:
Date:
Should be Empty:

Client Feedback Form

Congratulations on the birth of your baby! I am honored to have been present at such an intimate moment in your life. As part of my ongoing efforts to provide the best service possible, I ask each client to complete a feedback form. This helps me to know where I can improve my service.