Thank you for completing this short survey on your experience!

Dear Customer,

Thank you for allowing Copperstate Ambulance the opportunity to provide for your medical and transportation needs. Copperstate Ambulance has a continuous goal to improve our quality of service. Your comments and suggestions are important for us to achieve this goal.

So that we may provide you and your community with better service in the future, please take a few minutes to complete this survey. As a reminder, please do not include any personal health information when completing this survey—this includes, but is not limited to, personal health details such as diagnoses, medications, treatment history, or medical record numbers. If you would prefer to discuss our service in person, please list your name and phone number in the form below.

Again, thank you for entrusting us with your care!

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* 1. I would rate Copperstate Ambulance's overall service as?

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* 2. The field crew was professional, courteous, and neat in appearance?

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* 3. The field crew introduced themselves and the company?

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* 4. The field crew was attentive to my personal needs?

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* 5. The ambulance or wheelchair unit was clean and in good order?

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* 6. The ambulance or wheelchair environment was comfortable?

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* 7. The Communications staff (Dispatcher), was professional, courteous, and helpful?

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* 8. The Billing Department staff was professional, courteous, and helpful?

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* 9. I would use Copperstate Ambulance for my medical or transport needs in the future?

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* 10. The overall service provided met your expectations?

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* 11. Please provide any additional comments or feedback on your experience with Copperstate Ambulance.

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* 12. Please provide your name.

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* 13. Please provide your run number (on your invoice if available).

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* 14. What city did your service originate in?

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* 15. Would you like to be contacted about your comments on this form?

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* 16. If you would like to be contacted, please provide a phone number, email or other preferred method of contact.

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