| To
request more information, please complete the form
below. |
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Bold fields are
required
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Enter Patient
Name |
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Date of
Service |
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Day |
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Year |
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Please rate your experience with
Baldwin Ambulance below by choosing a number in the drop
down box following a question. "5" = Excellent, "3" = Average,
"1" = Poor, and "0" = didn't apply or n/a. For any area you
rate a "one" or "five" please breifly explain below so we may
use your imput to improve the quality of patient care of our
service to the community.
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Timeliness of
Response |
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Crew
Apperance |
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Cleanliness of
Ambulance |
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Crew
Professionalism |
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Crew Interaction with
Patient |
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Crew Interaction with
Family |
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Overall Care
Received |
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Overall Experience with
EMS |
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If you called the billing office,
rate your experience with them |
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Please Explain any 5's or 1's to
help us improve patient care |
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Name of person completing this
form |
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Relationship |
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Please include your
Email: |
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