Manatee County Emergency Medical Services Patient Survey

We are committed to providing you with the best experience possible. Please take a few minutes to fill out this survey on the timeliness and quality of the services you received.

Patient Billing Account Number or Name:

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1. Patient Billing Account Number or Name:

Date of Service

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2. Date of Service

MM/DD/YYYY
Dispatch 911

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3. Dispatch 911

  Outstanding Excellent Average Fair Poor N/A
Helpfulness of the person you called for ambulance service
Instructions given prior to arrival of the ambulance
Call handled in a prompt, courteous, and competent manner
Ambulance

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4. Ambulance

  Outstanding Excellent Average Fair Poor N/A
Timeliness of response to your location
Cleanliness of the ambulance and equipment
Comfort of the ride
Ambulance Crew

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5. Ambulance Crew

  Outstanding Excellent Average Fair Poor N/A
Professionalism of the crew
Information about your treatment
Care for you as a person
Request for patient information and delivery of privacy notice
Overall care received from the crew
Office Staff

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6. Office Staff

  Outstanding Excellent Average Fair Poor N/A
Professionalism of office staff
Willingness of staff to address your needs
If you interacted with our billing company, rate your overall experience
Overall Assessment

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7. Overall Assessment

  Outstanding Excellent Average Fair Poor N/A
Our staff worked together to care for you
Overall rating of the care provided by us
Additional comments for any questions that you rated outstanding or poor:

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8. Additional comments for any questions that you rated outstanding or poor:

If a member of our team was especially helpful, let us know who they are. We would like to share this information with them.

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9. If a member of our team was especially helpful, let us know who they are. We would like to share this information with them.

How many times have you used the ambulance service in the last 12 months?

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10. How many times have you used the ambulance service in the last 12 months?

Age group of patient

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11. Age group of patient

Contact Information (Optional)

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12. Contact Information (Optional)

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