mailto:chief@elchoems.orgPlease rate your experience with ELCHO EMS by choosing a selection from the drop down boxes following each question. For any area that you rate a "1" or "4" on, please briefly explain why in the provided box. Your input will be used to improve the quality of patient care that our service provides to the communities that we serve. 

Date of Service

-- mm/dd/yy

How was the timeliness of our response to your location?

mailto:chief@elchoems.org?subject=Form

How was the appearance of our crew?


How was the cleanliness of our ambulance?


 

How well did our staff explain billing forms and the privacy notice with you?


How would you rate your overall experience with Elcho EMS?


If you interacted with our billing staff, rate your overall experience with them:

 

If you would like to be contacted, please include the following information (optional):
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail

 

 
How was the professionalism of our crew?

How would you rate the crew's interaction with you?


How did the crew interact with your family and/or friends?


 

In order to help us improve the level of service that we provide, please explain any "4's" or "1's".


Name of person completing survey (optional):

Name