Care Survey
Date of Call
*
-
Month
-
Day
Year
Date
Address of Call
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would You Like to Sign Up for Email Updates From Milford-Holland Rescue?
*
Yes
No
Email
example@example.com
How Would You Rate the Respect and Professionalism of the Crew?
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Please Explain the Score Given.
How Would You Rate the Care Given?
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Please Explain the Score Given.
Did the Crew Simply and Entirely Explain Care and Treatment Provided to You?
*
Yes
No
If No Please Explain.
Do You Believe the Crew Acted in a Safe Manner Throughout the Contact?
*
Yes
No
If No Please Explain.
Do You Have Any Comments for the Crew?
*
Yes
No
Please Write Comments Here.
Do You Have Any Comments On What We Can Improve at Milford-Holland Rescue?
*
Yes
No
Please Write Comments Here.
Would You Like Us to Contact You About?
*
Yes
No
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do You Want to Receive a Receipt of Your Response?
*
Yes
No
Submit
Should be Empty: