* 1. Patient's Name:

* 2. Name of individual completing the feedback form:

* 3. Date of ambulance service:

Date:
/
/

* 4. Reason an ambulance was needed:

* 5. Did the ambulance arrive timely:

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

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

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

* 9. Were procedures and any treatment explained:

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

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

* 12. Would you like someone to contact you:

* 13. Any additional comments or suggestions:

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

Report a problem

T