Patient Satisfaction Survey

Name: *
Date of Service: *
Email: *

Did the Lancaster EMS vehicle arrive in a reasonable timeframe?	Yes	No
Was the crew courteous to you?	Yes	No
Did the crew perform in a professional manner?	Yes	No
Did the crew seem sensitive to your needs?	Yes	No
Did the crew make an effort to ensure your confidentiality?	Yes	No
If you were in pain, did the crew attempt to ease your pain?	Yes	No	N/A
Did you require treatment involving an I.V. or medication?	Yes	No
Did the crew explain any treatment administered to you?	Yes	No	N/A

Overall, how would you rate the services that you received?

Excellent

Good

Fair

Poor

What changes, if any, would you recommend?

Would you like someone to contact you about the care you received? Yes No
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Lancaster EMS (LEMSA)
1829 Lincoln Highway East • Lancaster, PA 17602
Local Phone: (717) 481-4841 • Fax: (717) 481-4845 •Email:
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