Patient's Name:

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* 1. Patient's Name:

Name of individual completing the feedback form:

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* 2. Name of individual completing the feedback form:

Date of ambulance service:

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* 3. Date of ambulance service:

Date:
Reason an ambulance was needed:

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* 4. Reason an ambulance was needed:

Did the ambulance arrive timely:

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* 5. Did the ambulance arrive timely:

Were the EMTs / Paramedics professional (with care and appearance):

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* 6. Were the EMTs / Paramedics professional (with care and appearance):

The EMTs / Paramedics were kind, caring, respectful and empathic:

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* 7. The EMTs / Paramedics were kind, caring, respectful and empathic:

Did the EMTs / Paramedics make reasonable efforts to ensure privacy / confidentiality:

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* 8. Did the EMTs / Paramedics make reasonable efforts to ensure privacy / confidentiality:

Were procedures and any treatment explained:

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* 9. Were procedures and any treatment explained:

Was the patient able to be transported to the patient's preferred (local) hospital:

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* 10. Was the patient able to be transported to the patient's preferred (local) hospital:

Overall, the care and transportation I received from Lancaster EMS was:

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* 11. Overall, the care and transportation I received from Lancaster EMS was:

Would you like someone to contact you:

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* 12. Would you like someone to contact you:

Any additional comments or suggestions:

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* 13. Any additional comments or suggestions:

May we share your responses with our team members and our medical director:

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* 14. May we share your responses with our team members and our medical director:

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