Patient / Service User Aftercare Survey

Patient / Service User Aftercare Survey

This survey is private and confidential.
Name*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Treatment / Transportation

MonthDayYear
Date
I was:*

Treated by Codeblue Medical (at an Event etc)Transported by Codeblue Medical Ambulance (Appointment)Transported by Codeblue Medical Ambulance (Emergency)Other
Please can you describe your experience with Codeblue Medical*
How satisfied are you with the Welcome from Medical Staff?*

1

2

3

4

5

1 is Very Dissatisfied, 5 is Extremely Satisfied
How satisfied are you with the Cleanliness of the Medical Area / Ambulance?*

1

2

3

4

5

1 is Very Dissatisfied, 5 is Extremely Satisfied
How satisfied are you with the Level of Care received today?*

1

2

3

4

5

1 is Very Dissatisfied, 5 is Extremely Satisfied
How satisfied are you that you were seen / treated in a timely manner?*

1

2

3

4

5

1 is Very Dissatisfied, 5 is Extremely Satisfied
How satisfied are you with the level of dignity and respect shown to you today?*

1

2

3

4

5

1 is Very Dissatisfied, 5 is Extremely Satisfied
How satisfied are you with the way things were explained to you today?*

1

2

3

4

5

1 is Very Dissatisfied, 5 is Extremely Satisfied
Overall, how satisfied are you with your overall experience with Codeblue Medical today?*

1

2

3

4

5

1 is Very Dissatisfied, 5 is Extremely Satisfied
How likely are you to recommend our services to friends and family?*

1

2

3

4

5

1 is Very Unlikely, 5 is Very Likely
If you have any further comments to make, please let us know here:
Should be Empty: