Patient Stories for AAA Industry Branding Project

Thank you for sharing your stories!

We know that ambulance services touch lives every day. Please help us shine a light on the impact of mobile healthcare in our communities by sharing stories from your patients. (Of course, please be sure to get their permission first! A sample HIPAA release is available for your use at http://ems.zone/hipaamedia).

We are looking for stories from all kinds of patients and their families, not just 911 response. Especially important are stories that show the human impact of EMS.

Have questions? Please contact ariordan@ambulance.org. Thanks again!

Question Title

* 1. Ambulance Service Details

Contact Person Name *

Ambulance Service Name *

City/Town *

State/Province

Email Address *

Phone Number *

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* 2. HIPAA Release Upload

Upload signed HIPAA release from patient, ir necessary. Need a template? Download on at http://ems.zone/hipaamedia

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 3. Patient Information

Name as the patient wishes it to appear (ex: "Eleanor R." or "Franklin Delano Roosevelt") *

City/Town

State/Province

Email Address

Phone Number

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* 4. Patient of Family Member Story or Quote

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* 5. Photo Upload

Upload photos of your patient reunion, crew, etc

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

Choose File

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* 6. Please check all that apply to this patient

Emergency / 911

Inter-facility Transfer

Mobile Integrated Health

Critical Care

Hospice

Patient is an infant

Patient is a child/teen

Patient is a senior/older adult

Patient has special needs

Heart attack

Trauma

Stroke

ROSC

Hospice

Natural Disaster

MCI

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* 1. Ambulance Service Details

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* 2. HIPAA Release Upload

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* 3. Patient Information

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* 4. Patient of Family Member Story or Quote

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* 5. Photo Upload

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* 6. Please check all that apply to this patient

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* 7. Anything Else We Should Know?