| Email
Address: |
* |
(We
will not disclose your email address.) |
| Patient
Number: |
* |
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| Date
of Service: |
* |
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| Patient's
Last Name: |
* |
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Please
rate our service by letting us know if you Strongly Agree, Agree,
No opinion, Disagree, or Strongly Disigree to the following
six questions. "5" means Strongly Agree, "4"
means Agree, "3" means No Opinion, "2" means
Disigree, and "1" means Strongly Disagree. |
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| 1)
The Crew was professional in appearance, demeanor and attitude. |
* |
| 2)
The ambulance was prompt. |
* |
| 3)
The Crew communicated well with me and my family. |
* |
| 4)
My concerns were well addressed. |
* |
| 5)
The Crew really seemed to care about my well being. |
* |
| 6)
I was comfortable with the decison to go or not go to the hospital. |
* |
| Comments: |
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| Do
you want us to contact you? |
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| If
so,how shall we contact you? |
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| Fields
marked with a (*) are required. |
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Thank
you for completing the Survey. Your feedback is important and
helps us provide the best service possible. |
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