Patient Feedback Survey

Perinton Ambulance is committed to providing the highest quality emergency medical services available to the communities we serve.

To measure our achievement of this mission, we look for feedback from those we serve; this survey is one of those measurement tools.

Any question marked with an asterisk (*) is required; all others are optional but are helpful for us to better serve you or respond to your feedback if you choose.

This form may not be used to request copies of PCRs or other official documentation regarding our services. For that information, please visit www.perintonambulance.org/patient-relations/privacy

Thank you for your feedback!

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* 1. Patient's name

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* 2. Patient's contact information (optional)

Email Address:

Phone Number:

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* 3. Patient's address (optional)

Street:

Apartment/Unit/etc:

City/Town:

State:

ZIP:

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* 4. Date of service (if unknown, leave blank)

MM/DD/YYYY

Date

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* 5. Location of EMS call for service

Company (if applicable)

Street (can be cross streets)

Apartment/Unit/etc.

City/Town:

State:

ZIP:

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* 6. Crew members' names (if known)

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* 7. Feedback

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* 8. Would you like someone to contact you regarding your experience?

Yes