Questionnaire – IUD Feedback

If you had an IUD fitted/replaced/removed/checked at The Quarter Jack Surgery in the past year, and have not already completed a feedback form, please submit your answers below.

Questionnaire – IUD feedback

Was your IUD...

Fitted/Replaced

Checked

Removed only

Please state month and year of procedure:

Insertion only

Were you offered appropriate counselling and advice before your IUD was fitted?

Yes

Was this the first IUD you have had fitted?

Yes

Did you have/were you advised to book a follow-up appointment?

Yes

Were you happy with the care you received at your appointment by the GP and/or nurse?

Yes

Do you have any feedback/comments that you would like us to consider?

If your comments need a reply, please give us your full name and contact details:

Finally, please could you tell us a little about yourself:

Age:

Gender:

Male

Female

Which ethnic group do you belong to?

White/White British

Black/Black British

Mixed

Chinese

Asian/Asian British

Other ethnic group

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