Patient Care Evaluation

Please take the time to let us know about your service. All surveys are confidential and used for the sole purpose of improving our service, patient care and staff. 

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* 1. Date of Service

Date / Time

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* 2. What was the purpose of your transport?

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* 3. Were you the Patient?

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* 4. What is the patients Age?

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* 5. Patient Gender

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* 6. Please Rate the Following questions 1-5
1= Poor    2= Fair   3= Average   4=Above Average   5= Excellent

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* 7. Is there anyone you would like to compliment or thank for their services?

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* 8. If you were not satisfied with the services you received please explain. If you would like someone from our department to call you to discuss your experience please leave your contact info.

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* 9. How can we improve our service?

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