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* 1. Please provide your full name?

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* 2. Please provide the date of service (on what date did the ambulance respond)?

Date

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* 3. Please provide the patients full name?

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* 4. Please provide the names, if possible, of the providers that treated you or your family?

Primary Provider Secondary Provider Crew 3 Crew 4 Crew 5
Crew Members

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* 5. The ambulance responded in a timely manner?

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* 6. The EMS personnel looked and acted professionally, and cared for me professionally and respectfully?

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* 7. The EMS personnel listened and showed concern for my questions and/or worries, and included me in treatment decisions?

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* 8. This space is reserved for compliments about the crew members or the service of Gaston County EMS.

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* 9. This space is reserved for complaints about the crew members or the service of Gaston County EMS.

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* 10. This area is reserved for suggestions for the services rendered by Gaston County EMS.

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* 11. Overall how satisfied were you with the services provided by the Gaston County EMS?

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* 12. Would you like to be contacted regarding a compliment, complaint, or suggestion?

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* 13. If you would like to be contacted regarding a compliment, complaint, or suggestion please provide your phone number or email here:

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